BIOLOGY 
LIBRARY 

* 


SURGICAL  APPLIED  ANATOMY 


SURGICAL 
APPLIED  ANATOMY 


BY 

SIR  FREDERICK  TREVES,   BART. 

G.G.V.O.,  G.B.,  LL.JK,  F.R.G.S.  Eng. 

Serjeant  Surgeon  to  H.M.  the  King;   Consulting  Surgeon  to 

the    London   Hospital ;    late    Lecturer   on   Anatomy   at  the 

London  Hospital 


SEVENTH  EDITION,   REVISED  BY 

ARTHUR  KEITH, 

M.D.,  LL.D.  Aber.,  F.R.G.S.  Eng.,  F.R.S. 

Hunterian  Professor  and  Conservator  of  the  Museum,  Royal 
College  of  Surgeons  of  England  ;  formerly  Lecturer  on  and 
Senior  Demonstrator  of  Anatomy  at  the  London  Hospital  ; 
Examiner  in  the  Universities  of  Aberdeen,  Cambridge,  etc. 


W.  COLIN  MACKENZIE, 

M.D.  Melb.,  F.R.C.S.  Edin.,  F.R.S.E. 

Member  of  Council    of   the   Anatomical  jsoqi^ty   of  Great 

Britain     and     Ire^an^  >     formerly     Lecturtr «.  on     Applied 

Anatomy1,  rjnJvprsfay  of  Melhq-irfke 


ILLUSTRATED  WITH' i53  FIGURES 

INCLUDING  74  IN   COLOUR 


LEA    &    FEBIGER 

Philadelphia    and    New    York 


l^    O   1 


\°\\ 


PREFACE   TO  THE   SEVENTH   EDITION 

ALTHOUGH  many  additions  have  been  made  to 
and  minor  alterations  effected  in  the  present 
edition,  this  book  still  retains  the  spirit,  form, 
and  size  given  to  it  by  its  distinguished  author. 
Every  chapter  has  been  revised  in  the  light  of 
recent  surgical  experience  and  progress.  War 
has  an  influence  even  on  such  a  manual  as  this, 
and  yet,  when  we  came  to  consider  how  far  the 
experience  of  our  Military  Surgeons  in  the  Field 
necessitated  modifications  of  the  text,  we  found 
that  Sir  Frederick  Treves  had  already  antici- 
pated most  of  our  modern  needs.  We  have  added 
considerably  to  what  may  be  called  "orthopaedic 
anatomy  " — the  kind  of  knowledge  which  is  neces- 
sary for  the  successful  treatment  of  stiffened 
joints  and  disabled  limbs.  Twenty-seven  new 
illustrations  have  been  introduced. 

We  intended  to  apply,  as  far  as  was  possible, 
the  new  Anatomical  Nomenclature,  but  the  further 
we  proceeded  with  its  application  the  more  we 
felt  that  we  should  do  British  Anatomy  and 
Surgery  an  ill  service  were  we  to  abandon  a  tried 
and  convenient  system  for  one  which,  in  many 
respects,  is  clumsy  and  imperfect.  What  we  have 
done  is  to  insert  the  new  names  side  by  side 
with  the  old  (some  of  the  new  terms  being 
advantageous),  so  that  those  who  prefer  the  new 
nomenclature  may  still  read  a  book  which  has 
been  used  so  widely  by  a  long  succession  of 
students  and  practitioners. 

A.  K. 
W.   C.  M. 

The  Museum, 

Royal  College  of  Surgeons  of  England. 
December,  1917. 


PREFACE    TO   THE    FIRST    EDITION 

APPLIED  ANATOMY  has,  I  imagine,  a  twofold  func- 
tion. On  the  one  hand  it  serves  to  give  a 
precise  basis  to  those  incidents  and  procedures  in 
practice  that  more  especially  involve  anatomical 
knowledge;  on  the  other  hand  it  endues  the  dull 
items  of  that  knowledge  with  meaning  and  interest 
by  the  aid  of  illustrations  drawn  from  common 
medical  and  surgical  experience.  In  this  latter 
aspect  it  bears  somewhat  the  same  relation  to 
Systematic  Anatomy  that  a  series  of  experiments 
in  Physics  bears  to  a  treatise  dealing  with  the 
bare  data  of  that  science. 

The  student  of  Human  Anatomy  has  often  a 
nebulous  notion  that  what  he  is  learning  will 
some  time  prove  of  service  to  him ;  and  may  be 
conscious  also  that  the  study  is  a  valuable,  if 
somewhat  unexciting,  mental  exercise.  Beyond 
these  impressions  he.  must  regard  his  efforts  as 
concerned  merely  in  the  accumulation  of  a  number 
of  hard,  unassimilable  facts.  It  should  be  one 
object  of  Applied  Anatomy  to  invest  these  facts 
with  the  interest  derived  from  an  association  with 
the  circumstances  of  daily  life;  it  should  make 
the  dry  bones  live. 

It  must  be  owned  also  that  all  details  in 
Anatomy  have  not  the  same  practical  value,  and 
that  the  memory  of  many  of  them  may  fade  with- 
out loss  to  the  competency  of  the  practitioner 
in  medicine  or  surgery.  It  should  be  one  other 
object,  therefore,  of  a  book  having  such  a  purpose 
as  the  present,  to  assist  the  student  in  judging 
of  the  comparative  value  of  the  mia^ter  he  has 


viii  PREFACE 

learnt;  and  should  help  him,  when  his  recollection 
of  anatomical  facts  grows  dim,  to  encourage  the 
survival  of  the  fittest. 

In  writing  this  manual  I  have  endeavoured,  so 
far  as  the  space  at  my  command  would  permit, 
to  carry  out  the  objects  above  described;  and 
while  I  believe  that  the  chief  matters  usually 
dealt  with  in  works  on  Surgical  Anatomy  have 
not  been  neglected,  I  have  nevertheless  tried  to 
make  the  principle  of  the  book  the  principle 
that  underlies  Mr.  Hilton's  familiar  lectures  on 
"Rest  and  Pain." 

I  have  assumed  that  the  reader  has  some  know- 
ledge of  Human  Anatomy,  and  have  not  entered, 
except  in  a  few  instances,  into  any  detailed 
anatomical  descriptions.  The  bare  accounts,  for 
example,  of  the  regions  concerned  in  Hernia  I 
have  left  to  the  systematic  treatises,  and  have 
dealt  only  with  the  bearings  of  the  anatomy  of 
the  parts  upon  the  circumstances  of  practice. 
The  limits  of  space  have  compelled  me  to  omit 
all  those  parts  of  the  "Surgery  of  the  Arteries  ' 
that  deal  with  ligature,  collateral  circulation, 
abnormalities,  and  the  like.  This  omission  I  do 
not  regret,  since  these  subjects  are  fully  treated 
not  only  in  works  on  operative  surgery,  but  also 
in  the  manuals  of  general  anatomy. 

The  book  is  intended  mainly  for  the  use  of 
students  preparing  for  their  final  examination 
in  surgery.  I  hope,  however,  that  it  will  be  of 
use  also  to  practitioners  whose  memory  of  their 
dissecting-room  work  is  growing  a  little  grey,  and 
who  would  wish  to  recall  such  anatomical  matters 
as  have  the  most  direct  bearing  upon  the  details 
of  practice.  Moreover,  it  is  possible  that  junior 
students  may  find  some  interest  in  the  volume, 
and  may  have  their  studies  rendered  more  in- 
telligent by  learning  how  anatomy  is  concerned 
in  actual  dealings  with  disease. 

FREDERICK  TREVES. 
September,  1883. 


CONTENTS 

PART  I.-THE   HEAD   AND   NECK 

CHAPTER  PAGW 

1.  THE  SCALP i 

2.  THE  BONY  VAULT  OF  THE  CRANIUM   ...  17 

3.  THE  CRANIAL  CONTENTS 34 

4.  THE  ORBIT  AND  EYE 55 

5.  THE  EAR  .....        .        .        .        .  87 

6.  THE  NOSE  AND  NASAL  CAVITIES  ....  105 

7.  THE  FACE        .        .  •      .        .        .       .        .        .121 

8.  THE  MOUTH,  TONGUE.  PALATE,  AND  PHARYNX  .  150 

9.  THE  NECK 173 

PART  IL— THE    THORAX 

10.  THE  CHEST  AND  ITS  VISCERA        ....  212 

PART  HL— THE   UPPER    EXTREMITY 

11.  THE  REGION  OF  THE  SHOULDER  ....  236 

12.  THE  ARM .  275 

13.  THE  REGION  OF  THE  ELBOW        ....  283 

14.  THE  FOREARM .  301 

15.  THE  WRIST  AND  HAND 310 

16.  THE  NERVE  SUPPLY  OF  THE  UPPER  EXTREMITY  335 


x      .  CONTENTS 

PART  IV.-THE   ABDOMEN   AND   THE  PELVIS 

OKAPTHB  PAGK 

17.  THE  ABDOMEN        .  347 

18.  THE  PERITONEUM  AND  ALIMENTARY  TRACT  .    386 

19.  THE  OTHER  ABDOMINAL  VISCERA        .        .  .     432 

20.  THE  PELVIS  AND  PELVIC  VISCERA      .        .  .465 

21.  THE  PERINEUM  475 


PART  V.— THE   LOWER   EXTREMITY 

22.  THE  REGION  OF  THE  HIP 523 

23.  THE  THIGH 561 

24.  THE  REGION  OF  THE  KNEE 569 

25.  THE  LEG .        .596 

26.  THE  ANKLE  AND  THE  FOOT 607 

PART  VL-THE   SPINE   AND   SPINAL  CORD 

27.  THE  SPINE 647 

28.  THE  SPINAL  CORD .659 

INDEX    .  675 


SURGICAL  APPLIED  ANATOMY 


PART  I.—THE    HEAD    AND    NECK 


CHAPTER    I 
THE    SCALP 

THE  soft  parts  covering:  the  vault  of  the 
skull  may  be  divided  into  five  layers  :  (1)  the 
skin,  (2)  the  subcutaneous  fatty  tissue,  (3)  the 
occipito-frontalis  or  epicranial  muscle  and  its 
aponeurosis,  (4)  the  subepicranial  connective 
tissue,  and  (5)  the  pericranium.  It  is  convenient 
to  consider  the  term  "  scalj)  "  as  limited  to  the 
structure  formed  by  the  union  of  the  first  three 
layers  above  named  (Fig.  1). 

The  skin  of  the  scalp  is  thicker  than  in  any 
other  part  of  the  body.  It  is  in  all  parts  in- 
timately adherent,  by  means  of  the  subcutaneous 
tissue,  to  the  aponeurosis  and  muscle  beneath  it, 
and,  from  this  adhesion,  it  follows  that  the  skin 
moves  in  all  movements  of  that  muscle.  The  sub- 
cutaneous tissue  is,  like  a  similar  tissue  in  the 
pahn,  admirably  constructed  to  resist  pressure, 
being  composed  of  a  multitude  of  fibrous  bands 
enclosing  fat  lobules  in  more  or  less  isolated  spaces 
(Fig.  1,  6).  The  density  of  the  scalp  is  such,  that 
in  surface  inflammations,  such  as  cutaneous  ery- 
sipelas, it  is  unable  to  offer  (except  in  a  very 
slight  degree)  two  conspicuous  features  of  such 
inflammations,  viz.  redness  and  swelling.  The  skin 


THE    HEAD    AND*  NECK 


[CHAP. 


is   projected    wJtii  ;a/£ieit    number    of 
glandsj  which  may*  develoiKinl  o  cystic  t 

* 


sebaceous 
tumours  or 

wejnrs  sjU.iIgygtf  &  TjIwiginAre*  common  upon  the  scalp 
tha'rf'in*  any  'other  :p«tf^*  of  »  the  body.  Being  skin 
growths,  these  cysts,  even  when  large,  remain,  ex- 


-ct 
-I 

•  -c 

•-cl 

•  ~e 


f 


Fig.   1. — Diagram  showing    the    layers    of   the    scalp    and 
membranes  of  the  brain  in  section. 

a,  Skin  ;  b,  subcutaneous  tissue  with  hair  roots  and  vessels  :  <•,  epi- 
cranius ;  d,  subepicranial  layer ;  e,  pericranium  ;  /',  parietal 
bone  ;  g,  dura  mater  ;  it,  arachnoid ;  I,  pia  mater  ;  m,  cortex  ; 
n,  in  subdural  space  near  a  Pacchionian  body  projecting  within 
the  superior  longitudinal  sinus, 

cept  in  rare  instances,  entirely  outside  the  epi- 
cranius,  and  can  therefore  be  removed  without 
risk  of  opening  up  the  area  of  loose  connective 
tissue  between  the  epicranial  fascia  and  the  peri- 
cranium. 

There  being  no  fatty  tissue  in  any  of  the  layers 
that  cover  the  bony  vault  save  in  the  subcutaneous 


i]  THE   SCALP 

layer,  it  happens  that  in  cases  of  obesity  the  scalp 
undergoes  but  little  change,  the  fat  in  the  subcu- 
taneous tissue  being  limited  by  the  dense  fibrous 
structures  that  enclose  it.  For  the  same  reasons 
fatty  tumours  of  the  scalp  are  very  rare.  The 
attachment  of  the  hairs  collectively  to  the  scalp 
is  so  strong  that  there  are  many  cases  where  the 
entire  weight  of  the  body  has  been  supported  by 
the  hair  of  the  scalp.  Agnew  records  the  case  of 
a  woman  whose  hair  became  entangled  in  the  re- 
volving shaft  of  a  machine.  The  hair  did  not  give 
way,  but  the  entire  scalp  was  torn  off  from  the 
skull.  The  patient  recovered 

Dangerous  area  of  the  scalp.  —  Between 
the  epicranius  and  the  pericranium  is  an  exten- 
sive layer  of  loose  connective  tissue,  that  may,  for 
reasons  to  be  presently  'given,  be  fairly  called 
the  dangerous  area  of  the  scalp  (Fig.  1,  d).  The 
mobility  of  the  scalp  depends  entirely  upon  the 
laxity  of  this  layer  of  tissue.  In  extensive  scalp 
wounds,  when  a  part  of  the  scalp  is  separated  in 
the  form  of  a  large  flap,  a  flap  that  may  hang 
down  and  cover  half  the  face,  it  is  the  very  loose- 
ness of  this  tissue  that  permits  such  separation. 
The  exposure  of  the  skull  in  a  post-mortem 
examination  is  effected  by  peeling  off  the  scalp 
along  this  layer  of  loose  tissue,  and  it  is  remark- 
able with  what  ease  the  skull  can  be  exposed  by 
this  manoeuvre. 

Wound*  of  the  scalp  never  gape,  unless  the 
wound  has  involved  the  scalp  muscle  or  its  apo- 
neurosis.  When  this  structure  has  been  divided 
the  lax  layer  beyond  permits  of  great  separation  of 
the  edges  of  ^even  the  simplest  wounds.  In  uncom- 
plicated incised  wounds,  the  amount  of  gaping  of 
the  cut  depends  upon  the  action  of  the  epicranius 
or  occipito-frontalis  muscle.  Those  wounds  gape 
the  most  that  are  made  across  the  muscle  itself, 
and  that  are  transverse  to  the  direction  of  its 
fibres,  while  those  show  the  least  separation  that 
involve  the  aponeurosis  and  are  made  in  an  antero- 
posterior  direction.  The  mobility  of  the  scalp  is 


4  THE    HEAD    AND    NECK  [CHAP. 

more  marked  in  the  young  than  in  the  old.  A  case 
recorded  by  Agnew  serves  in  a  strange  degree  to 
illustrate  this  fact  in  the  person  of  an  infant.  A 
midwife  attending  a  woman  in  labour  mistook 
the  scalp  of  the  infant  for  the  membranes,  and 
gashed  it  with  a  pair  of  scissors.  Labour  pains 
came  on  and  the  head  was  protruded  through  the 
scalp  wound,  so  that  the  whole  vault  of  the  skull 
was  peeled  like  an  orange.  The  scalp  being  firmly 
stretched  over  the  hard  cranium  beneath,  it  follows 
that  contused  wounds  often  appear  as  cleanly  cut 
as  are  those  that  have  been  made  by  an  incision. 
Such  wounds  may  be  compared  to  the  clean  cut 
that  may  be  made  in  a  kid  glove  when  it  is  tightly 
stretched  over  the  knuckles  and  those  parts  are 
sharply  rapped. 

The  scalp  is  extremely  vascular,  and  presents 
therefore  a  great  resistance  to  sloughing  and  gan- 
grenous conditions.  Large  flaps  of  a  lacerated 
scalp,  even  when  extensively  separated  and  almost 
cut  off  from  the  rest  of  the  head,  are  more  prone 
to  live  than  to  die.  A  like  flap  of  skin,  separated 
from  other  parts  of  the  surface,  would  most  prob- 
ably perish ;  but  the  scalp  has  this  advantage,  that 
the  vessels  run  practically  in  the  skin  itself,  or 
are,  at  least,  in  the  tissue  beyond  the  aponeurosis 
(Fig.  1).  Thus,  when  a  scalp  flap  is  torn  up,  it 
still  carries  with  it  a  very  copious  blood  supply. 
Bleeding  from  these  wounds  is  usually  very  free, 
and  often  difficult  to  arrest.  This  depends  not 
so  much  upon  the  number  of  vessels  in  the  part  as 
upon  the  density  of  the  tissue  through  which  these 
vessels  run,  the  adherence  of  the  outer  arterial 
wall  to  the  scalp  structure,  and  the  inability, 
therefore,  of  the  artery  to  retract  properly  when 
divided.  For  the  same  reason  it  is  almost  im- 
possible to  pick  up  an  artery  divided  in  a  scalp 
wound.  The  bleeding  is  checked  by  a  hare-lip 
pin  or  by  pressure. 

In  all  parts  of  the  body  where  a  dense  bone  is 
covered  by  a  comparatively  thin  layer  of  soft 
tissues,  sloughing  of  those  tissues  is  apt  to  be 


ij  THE    PERICRANIUM  5 

induced  by  long  and  severe  pressure.  The  scalp, 
by  its  yascularity,  is  saved  to  a  great  extent  from 
this  evil,  and  is  much  less  liable  to  slough  than 
are  the  soft  parts  covering  such  bones  as  the  con- 
dyles  of  the  humerus  or  the  sacrum.  But  such 
an  effect  is  sometimes  produced,  as  in  a  case  I 
(F.  T.)  saw,  where  the  tissues  over  the  frontal 
and  occipital  regions  sloughed  from  the  continued 
application  of  a  tight  bandage  put  on  to  arrest 
bleeding  from  a  frontal  wound. 

The  pericranium  is  but  slightly  adherent  to 
the  bone,  except  at  the  sutures,  where  it  is  inti- 
mately united  (Fig.  1,  e).  In  lacerated  wounds 
this  membrane  can  be  readily  stripped  from  the 
skull,  and  often,  in  these  injuries,  extensive  tracts 
of  bone  are  laid  bare.  The  pericranium  differs 
somewhat  in  its  functions  from  the  periosteum 
that  covers  other  bones.  If  the  periosteum  be 
removed  to  any  extent  from  a  bone,  the  under- 
lying laminae  will  very  probably  perish,  and 
necrosis  from  deficient  blood  supply  result.  But 
the  pericranium  may  be  stripped  off  a  con- 
siderable part  of  the  skull  vault  without  any 
necrosis,  save  perhaps  a  little  superficial  ex- 
foliation. This  is  explained  by  the  fact  that 
the  cranial  bones  derive  their  blood  supply 
mainly  from  the  dura  mater,  and  are  therefore 
to  a  considerable  extent  independent  of  the 
pericranium.  A  like  independence  cannot  be 
claimed  for  the  periosteum  covering  other  bones, 
since  that  membrane  brings  to  the  part  it  covers 
a  very  copious  and  essential  contribution  to  its 
blood  supply.  This  disposition  of  the  pericran- 
ium is  also  well  illustrated  by  its  action  in  cases 
of  necrosis  of  the  cranial  bones.  In  necrosis  of  a 
long  bone,  the  separation  of  the  sequestrum  is 
attended  with  a  vigorous  periosteal  growth  of 
new  bone,  which  repairs  the  gap  left  after  the  re- 
moval of  such  sequestra.  In  necrosis  of  the  vault 
of  the  skull,  however,  no  new  bone  is  formed,  as 
a  rule,  and  the  gap  remains  unrepaired.  The 
general  indisposition  of  the  pericranium  to  form 


6  THE    HEAD    AND    NECK  [CHAP 

new    bone    in    other   circumstances    is    frequently 
illustrated. 

Abscesses  in  the  scalp  region  may  be  situated 
(1)  above  the  epicranial  aponeurosis,  (2)  between  the 
aponeurosis  and  the  pericranium,  and  (3)  beneath 
the  pericranium.  Abscesses  in  the  first  situation 
must  always  be  small  and  comparatively  insignifi- 
cant, since  the  density  of  the  scalp  tissue  here  is 
such  that  suppuration  can  only  extend  with  the 
greatest  difficulty.  Suppuration,  however,  in  the 
second  situation  (in  the  loose  tissue  beneath  the 
aponeurosis)  may  prove  very  serious.  The  laxity 
of  this  tissue  offers  every  inducement  to  the  ab- 
scess to  extend  when  once  pus  has  found  its  way 
between  the  aponeurosis  and  the  pericranium. 
Suppuration  in  this  area  may  undermine  the  en- 
tire scalp,  which  in  severe  and  unrelieved  cases 
may  rest  upon  the  abscess  beneath  as  upon  a  kind 
of  water-bed.  As  in  scalp  wounds,  the  aponeu- 
rosis is  often  divided,  and  as  suppuration  may 
follow  the  injury,  it  will  be  seen  that  the  chief 
danger  of  those  lesions  depends  upon  the  spread- 
ing of  such  suppuration  to  the  area  of  lax  con- 
nective tissue  now  under  notice.  The  significance 
of  a  small  amount  of  bare  bone  in  a  scalp  wound 
is  not  so  much  that  evils  will  happen  to  the 
bone  as  that  the  aponeurosis  has  been  certainly 
divided  and  the  dangerous  area  of  the  scalp 
opened  up.  Suppuration,  when  it  occurs  in  this 
area,  is  only  limited  by  the  attachments  ^of  the 
occipito-frontalis  muscle  and  its  aponeurosis,  and 
therefore  the  most  dependent  places  through  which 
pus  can  be  evacuated  are  situated  along  a  line 
drawn  round  the  head,  commencing  in  front,  above 
the  eyebrow,  passing  at  the  side  a  little  above  the 
zygoma,  and  ending  behind  at  the  superior  curved 
line  of  the  occipital  bone.  The  scalp,  even  when 
extensively  dissected  up  by  such  abscesses,  does 
not  perish,  since  it  carries,  as  above  explained,  its 
blood  supply  with  it.  The  abscess  is  often  very 
slow  to  close,  since  its  walls  are  prevented  from 
obtaining  perfect  rest  by  the  frequent  movement 


i]  H.EMATOMATA   OF   THE   SGALP  7 

of  the  epicranial  muscle.  To  mitigate  this  evil, 
and  to  ensure  closing  of  the  sinuses  in  obstinate 
cases,  Hilton  advises  that  the  whole  scalp  be 
firmly  secured  by  strapping,  so  that  the  movement 
of  the  muscle  is  arrested. 

Abscesses  beneath  the  pericranium  must  be 
limited  to  one  bone,  since  the  dipping-in  of  the 
membrane  at  the  sutures  prevents  a  more  exten- 
sive spreading  of  the  suppuration. 

Hrematomata,  or  blood  tumours,  of  the 
scalp  region  occur  in  the  same  localities  as  ab- 
scesses. The  extravasation  of  blood  above  the  apo- 
neurosis  must  be  of  a  limited  character,  while  that 
beneath  it  may  be  very  extensive.  It  fortunately 
happens,  however,  that  the  cellular  tissue  between 
the  aponeurosis  and  the  pericranium  contains  but 
very  few  vessels,  and  hence  large  extravasations  in 
this  tissue  are  uncommon. 

Extravasations  of  blood  beneath  the  peri- 
cranium are  generally  termed  cephalhsematomata, 
and  are  of  necessity  limited  to  one  bone.  They 
are  usually  due  to  pressure  upon  the  head  at 
birth,  and  are  thus  most  commonly  found  over 
one  parietal  bone,  that  bone  being  probably  the 
one  most  exposed  to  pressure.  Their  greater  fre- 
quency in  male  children  may  depend  upon  the 
larger  size  of  the  head  in  the  male  foetus.  Such 
extravasations  in  early  life  are  encouraged  by 
the  laxity  of  the  pericranium,  and  by  the  softness 
and  vascularity  of  the  subjacent  bone. 

In  the  temporal  region,  or  the  region  corre- 
sponding to  the  temporal  muscle,  the  layers  of  soft 
parts  between  the  skin  and  the  bone  are  some- 
what different  from  those  that  have  been  already 
described  as  common  to  the  chief  parts  of  the  scalp. 
There  is  a  good  deal  of  fat  in  the  temporal  fossa, 
and  when  this  is  absorbed  it  leads  to  more  or  less 
prominence  of  the  zygoma  and  malar  bone,  and 
so  produces  the  projecting  "cheek  bones"  of  the 
emaciated.  The  temporal  muscle  above  the  zy- 
goma is  covered  in  by  a  very  dense  fascia,  the 
temporal  fascia,  which  is  attached  above  to  the 


8  THE    HEAD    AND    NEGK  [CHAP. 

temporal  ridge  on  the  frontal  and  parietal  bones, 
and  below  to  the  zygomatic  arch.  The  unyielding 
nature  of  this  fascia  is  well  illustrated  by  a 
case  recorded  by  Denonvilliers.  It  concerned  a 
woman  who  had  fallen  in  the  street,  and  was  ad- 
mitted into  hospital  with  a  deep  wound  in  the 
temporal  region.  A  piece  of  bone  of  several  lines 
in  length  was  found  loose  at  the  bottom  of  the 
wound,  and  was  removed.  After  its  removal  the 
finger  could  be  passed  through  an  opening  with 
an  unyielding  border,  and  came  in  contact  with 
some  soft  substance  beyond.  The  case  was  con- 
sidered to  be  one  of  compound  fracture  of  the 
squamous  bone,  with  separation  of  a  fragment 
and  exposure  of  the  brain.  A  bystander,  however, 
noticed  that  the  bone  removed  was  dry  and  white, 
and  a  more  complete  examination  of  the  wound 
revealed  the  fact  that  the  skull  was  uninjured, 
that  the  supposed  hole  in  the  skull  was  merely 
a  laceration  of  the  temporal  fascia,  that  the  soft 
matter  beyond  was  muscle  and  not  brain,  and  that 
the  fragment  removed  was  simply  a  piece  of  bone 
which,  lying  on  the  ground,  had  been  driven  into 
the  soft  parts  when  the  woman  fell. 

Abscesses  in  the  temporal  fossa  are  prevented 
by  the  fascia  from  opening  anywhere  above  the 
zygoma,  and  are  encouraged  rather  to  spread  into 
the  pterygoid  and  maxillary  regions  and  into  the  neck. 

The  pericranium  is  much  more  adherent  to 
the  bone  in  the  temporal  region  than  it  is  over 
the  rest  of  the  vault,  and  subpericranial  extrava- 
sations of  blood  are  therefore  practically  unknown 
in  this  part  of  the  cranial  wall. 

Vessels  and  nerves  of  the  scalp.—  The 
supraorbital  artery  and  nerve  pass  vertically  up- 
wards from  the  supraorbital  notch,  which  is  situ- 
ate at  the  junction  of  the  middle  with  the  inner 
third  of  the  upper  orbital  margin.  Nearer  the 
middle  line  the  frontal  artery  and  supratrochlear 
nerve  ascend.  This  artery  gives  life  to  the  flap 
that  in  rhinoplasty  is  taken  from  the  forehead 
to  form  a  new  nose.  The  temporal  artery,  with 


i]  VESSELS   OF  THE   SCALP  9 

the  auriculo-temporal  nerve  behind  it,  crosses  the 
base  of  the  zygoma  just  in  front  of  the  ear.  The 
vessel  divides  into  its  two  terminal  branches  (the 
anterior  and  posterior)  2  inches  above  the  zygoma. 
The  branches  of  this  artery,  especially  the  an- 
terior branch,  are  often  very  tortuous  in  the  aged, 
and  afford  early  evidence  of  arterial  degeneration. 
Arteriotomy  is  sometimes  practised  on  the  an- 
terior branch  of  this  vessel.  The  superficial  tem- 
poral vessels  are  very  liable  to  be  the  seat  of 
cirsoid  aneurysm,  as,  to  a  less  extent,  are  the  other 
scalp  arteries.  The  posterior  auricular  artery  and 
nerve  run  in  the  groove  between  the  mastoid 
process  and  the  ear,  and  the  occipital  artery  and 
the  great  occipital  nerve  reach  the  scalp  just 
internally  to  a  point  midway  between  the  occi- 
pital protuberance  and  the  mastoid  process. 

Certain  of  the  emissary  veins  are  of  import- 
ance in  surgery.  These  veins  pass  through  aper- 
tures in  the  cranial  wall,  and  establish  communi- 
cations between  the  venous  circulation  (the 
sinuses)  within  the  skull  and  the  superficial  veins 
external  to  it.  The  principal  emissary  veins  are 
the  following  :  1.  A  vein  passing  through  the  mas- 
toid foramen  and  connecting  the  lateral  sinus 
with  the  posterior  auricular  vein  or  with  an  occi- 
pital vein.  This  is  the  largest  and  most  constant 
of  the  series.  The  existence  of  this  mastoid  vein 
serves  to  answer  the  question,  Why  is  it  a  com- 
mon practice  to  apply  leeches  and  blisters  behind 
the  ear  in  certain  cerebral  affections  1  2.  A  vein 
connecting  the  superior  longitudinal  sinus  with 
the  veins  of  the  scalp  through  the  parietal  foramen. 
3.  A  vein  connecting  the  lateral  sinus  with  the 
deep  veins  at  the  back  of  the  neck  through 
the  posterior  condylic  foramen  (inconstant).  4. 
Minute  veins  following  the  twelfth  nerve  through 
the  anterior  condylic  foramen,  and  connecting  the 
occipital  sinus  with  the  deep  veins  of  the  neck. 
5.  Minute  veins  passing  through  the  foramen 
ovale,  foramen  of  Vesalius,  foramen  lacerum 
medium,  and  carotid  canal,  to  connect  the  cavern- 


10  THE    HEAD    AND    NECK  [CHAP. 

ous  sinus  with  (respectively)  the  pterygoid  venous 
plexus,  the  pharyngeal  plexus,  and  the  internal 
jugular  vein. 

Then,  again,  many  minute  veins  connect  the 
veins  of  the  scalp  with  those  of  the  diploe.  Of  the 
four  diploic  veins,  two  (the  frontal  and  anterior 
temporal)  enter  into  surface  veins  (the  supra- 
orbital  and  deep  temporal),  and  two  (the  pos- 
terior temporal  and  occipital)  enter  into  the 
lateral  sinus. 

Lastly,  there  is  the  well-known  communication 
between  the  extra-  and  intracranial  venous  circu- 
lation effected  by  t^e  commencement  of  the  facial 
vein  at  the  inner  angle  of  the  orbit.  In  this  com- 
munication the  angular  and  supraorbital  veins 
unite  with  the  superior  ophthalmic  vein,  a  tribu- 
tary of  the  cavernous  sinus.  The  veins  within  the 
cavities  of  the  nose  and  middle  ear  also  communi- 
cate with  those  of  the  meninges. 

Through  these  various  channels,  and  through 
many  probably  still  less  conspicuous,  inflammatory 
processes  can  spread  from  the  surface  to  the  in- 
terior of  the  skull.  Thus  we  find  such  affections  as 
erysipelas  of  the  scalp,  diffuse  suppuration  of  the 
scalp,  necrosis  of  the  cranial  bones,  and  the  like, 
leading  by  extension  to  mischief  within  the  diploe, 
to  thrombosis  of  the  sinuses,  and  to  inflammation 
of  the  meninges  of  the  brain.  If  there  were  no 
emissary  veins,  injuries  and  diseases  of  the  scalp 
and  skull  would  lose  half  their  seriousness.  Mis- 
chief may  even  spread  from  within  outwiards  along 
an  emissary  vein.  Erichsen  reports  a  case  where 
the  lateral  sinus  was  exposed  in  a  compound  frac- 
ture. The  aperture  was  plugged.  Thrombosis  and 
suppuration  within  the  sinus  followed,  and  some  of 
the  pus,  escaping  through  the  mastoid  vein,  led  to 
an  abscess  in  the  neck. 

Certain  venous  tumours  are  met  with  on  the 
skull.  They  consist  of  collections  of  venous  blood 
under  the  pericranium  that  communicate,  through 
holes  in  the  skull,  with  the  superior  longitudinal 
sinus.  They  are  median,  are  reducible  on  pressure, 


i]         VENOUS   TUMOURS   ON   THE   SKULL         11 

and  receive  a  faint  pulsation  from  the  brain.  The 
holes  are  sometimes  the  result  of  accident,  others 
depend  upon  bone  disease  or  atrophy  over  a  Pac- 
chionian  body,  and  a  few  are  due  to  a  varicose 
emissary  vein  or  to  a  congenital  defect  in  the 


Fig.  2. — Nerve  areas  of  the  face  and  scalp. 

A,  A,  Distribution  of  the  first  division  of  the  fifth  cranial  nerve:  A  , 

nasal  branch  ;  A",  supratrochlear ;  A'",  supraorbital. 

B,  B,  Distribution  of  the  second  division :  B',  infraorbital  branch  ; 

B",  malar  branch  ;  B'",  temporal  branch. 

C,  C,  Distribution  of  third  division :  c',  mental  branch ;  C  ,  buccal 

branch ;  C'",  auriculo-temporal. 

1,  Area  of  great  occipital ;  2,  of  small  occipital ;  3,  of  great  auricular  ; 
4,  of  superficial  cervical ;  5  of  third  occipital. 

cranium,   especially  in  the  neighbourhood  of  the 
parietal  foramina. 


12  THE    HEAD    AND    NECK  [CHAP. 

The  scalp  nerves,  especially  such  as  are  branches 
of  the  fifth  pair,  are  often  the  seat  of  neuralgia 
(Fig.  2).  To  relieve  one  form  of  this  affection,  the 
supraorbital  nerve  has  been  divided  (neurotomy), 
or  paralysed  by  an  injection  of  absolute  alcohol 
at  its  point  of  exit  from  the  orbit.  Some  forms 
of  frontal  headache  depend  upon  neuralgia  of 
this  nerve.  The  inner  or  medial  branch  of  the 
nerve  reaches  the  middle  of  the  parietal  bone ;  the 
outer  branch,  the  lambdoid  suture. 

The  lymphatics  from  the  occipital  and  posterior 
parietal  regions  of  the  scalp  enter  the  occipi- 
tal and  mastoid  glands;  those  from  the  frontal 
and  anterior  parietal  regions  go  to  the  parotid 
glands,  while  some  of  the  vessels  from  the  frontal 
region  join  the  lymphatics  of  the  face  and  end  in 
the  submaxillary  glands  (Fig.  50,  p.  207). 

Trephining. — This  operation  is  one  of  the 
oldest  in  surgery.  We  know  that  it  was  exten- 
sively practised  in  France  more  than  six  thousand 
years  ago,  for  skulls  of  that  period  show  un- 
mistakable signs  of  having  been  successfully 
trephined.  At  the  present  day  this  operation  is 
frequently  performed  in  the  temporal  region,  one 
object  being  to  reach  extravasations  of  blood  from 
the  middle  meningeal  veins  or  artery.  These 
vessels  cross  the  anterior  inferior  or  sphenoidal 
angle  of  the  parietal  bone  at  a  point  1^  inches 
behind  the  malar  or  external  angular  process 
of  the  frontal  bone,  and  li  inches  above  the 
zygoma.  In  cutting  down  to  expose  these  vessels 
the  following  structures  are  met  with  in  order : 
(1)  The  skin ;  (2)  branches  of  the  superficial  tem- 
poral vessels  and  nerves;  (3)  the  fascia  continued 
down  from  the  epicranial  aponeurosis;  (4)  the 
temporal  fascia ;  (5)  the  temporal  muscle ;  (6)  the 
deep  temporal  vessels;  (7)  the  pericranium;  (8) 
the  sphenoidal  angle  of  the  parietal  bone. 

Trephining:  for  meningeal  haemorrhage  and 
cerebral  abscess.  -At  the  sphenoidal  angle  of  the 
parietal  bone  the  anterior  division  of  the  middle 
meningeal  artery  lies  with  its  companion  veins 


I] 


TREPHINING 


13 


in  a  deep  groove  or  even  canal  in  the  bone. 
A  fracture  of  the  bone,  which  is  comparatively 
thin  in  the  region  of  the  pterion,  is  almost  certain 
to  rupture  the  veins,  and  may  also  involve  the 
artery,  leading  to  a  subdural  haemorrhage,  with 
consequent  compression  of  the  brain.  The  pterion 
lies  1-|  inches  behind  and  ^  an  inch  above  the  notch 
of  the  fronto-malar  (fronto-zygomatic)  suture— a 


BR.CCJAIA 


.COROA1AL5UTUR& 


SUP. TEM. LIME 


EXT  AUDITOR 

OCCIPITAL  AR.T 


IftT    JUQULAH  VEIrt 

EXT  CAROTID  ART 


Fig.  3.— Points  to  trephine  for  middle  meningeal  vessels 
and  lateral  sinus. 


point  which  can  be  readily  felt  (Fig.  3).  Similar 
measurements — namely,  lj  inches  behind  and  \  an 
inch  above— taken  from  the  centre  of  the  external 
auditory  meatus — the  meatal  point,  give  the  posi- 
tion of  the  posterior  inferior  angle  of  the  parietal 
bone  (asterion),  beneath  which  lies  the  highest 
point  of  the  lateral  sinus  (Fig.  3).  A  trephine 
opening,  f  of  an  inch  in  diameter,  made  over  the 
asterion,  will  expose  the  lateral  sinus,  and  give 
access  to  the  temporo-sphenoidal  lobe  above  it 


14  THE    HEAD    AND    NECK  [CHAP. 

and  to  the  cerebellum  below  it.  The  posterior 
division  of  .the  middle  meningeal,  in  the  majority 
of  cases,  will  be  exposed  by  trephining  at  a  point 
1  inch  above  the  external  auditory  meatus.  These 
measurements  apply  to  the  head  of  the  average 
adult;  allowance  must  be  made  for  youth  and 
for  the  size  and  shape  of  the  head.  In  finding 
the  pterion,  a  line  is  drawn  backwards  parallel 
to  the  upper  border  of  the  zygoma;  in  finding 
the  asterion,  a  line  is  drawn  backwards  along  the 
meato-inionic  line  (Fig.  3),  which  passes  from  the 
centre  of  the  external  meatus  to  the  most  promi- 
nent point  of  the  external  occipital  protuberance 
— the  inion. 

It  may  also  be  necessary  to  trephine  for  an 
abscess  of  the  temporal  lobe,  the  pus  being 
usually  found  in  that  part  of  the  lobe  which  lies 
over  the  tegmen  tympani — a  thin  plate  of  bone 
which  forms  the  roof  of  the  tympanum  and  of  the 
antrum  of  the  mastoid.  The  level  of  the  tegmen 
may  be  indicated  thus  (Fig.  4)  :  A  point  is  taken 
above  the  meatus  in  line  with  the  upper  border  of 
the  zygoma;  this  suprameatal  point  is  joined 
with  the  asterion,  which  lies,  it  will  be  remem- 
bered, 1^  inches  behind  and  ^  an  inch  above  the 
meatus;  the  anterior  half  of  the  above  line  corre- 
sponds to  the  tegmen  tympani.  A  trephine  open- 
ing made  1  inch  above  the  level  of  the  tegmen 
is  the  most  likely  to  give  access  to  an  abscess 
situated  in  the  temporal  lobe 

In  dealing  with  an  abscess  of  the  cerebellum 
the  best  spot  to  select  is,  in  the  adult,  1^  inches 
behind  the  centre  of  the  meatus  and  J  of  an  inch 
below  the  meato-inionic  line.  In  some  cases  it 
is  impossible  to  say  whether  the  abscess  is 
situated  in  the  temporal  lobe  or  the  cerebellum. 
In  such  cases  trephining  should  be  performed  at 
a  point  which  lies  1  finches  behind  and  \  of  an  inch 
above  the  centre  of  the  meatus.  The  lateral  sinus 
is  thus  exposed  with  a  part  of  the  dura  mater 
above  the  tentorium_  cerebelli,  through  which  the 
temporal  lobe  may  "be  explored.  By  extending 


TREPHINING 


15 


the  trephine  opening  |  an  inch  downwards  the 
cerebellum  may  be  examined. 

Trephining  for  cerebral  tumour. — The  position 
of  the  opening  in  the  skull  is  obviously  determined 
by  the  localizing  symptoms.  It  is  remarkable  that 
little  trouble  from  haemorrhage  has  attended  these 
operations. 

In  any  case,  after  trephining,  the  portion  or 
portions  of  bone  removed  may — if  properly 
treated— be  replaced  in  the  opening,  and  will 


FRONTAL  POLE 
ANTERIOR  noun 

flSSUREor  SYLVIUS 


UPPER  ROLANDO  POINT 


FISSURE  OF  ROLANDO 


PARIETAL  EMINENCE 

PARIETO  OCCIPITALFISSURI 

LAMBDA 

FOR  LATERAL  VENTRICLE- 

POST.  hoa.n 
DESC.MORAI 
FOR  TEMP-SP«EN.  ABSCESS 

OCCIPITAL  POLE 
ON 

CEREBELLUM 


ASTERIOM 

TYMPANIC  PLATE 

5llPRAMEATAL    TRIANCLE 

'AIE.ATUS 

SuPRANEATAL  POINT  , 

Fig.  4. — Diagram  to  show  the  position  of  the  lateral  ven- 
tricles, the  insula  (island  of  Reil),  and  the  temporal  pole. 

serve,    especially   in   youthful   subjects,    to   make 

food  the  gap  left  by  the  operation.     The  ostep- 
lasts  in  the  fragments  remain  alive  and  retain 
the  power  of  bone-formation. 

In  trephining  the  skull,  the  comparative  thick- 
ness of  the  cranial  wall  in  various  parts  should 
be  borne  in  mind,  and  the  large  arteries  of  the 
scalp  should,  if  possible,  be  avoided.  In  order 
to  accommodate  the  instrument  to  the  varying 
thickness  of  the  skull,  the  pin  of  the  trephine 
is  not  allowed  to  protrude  more  than  •&  of  an 
inch.  In  the  temporal  fossa  the  bone  varies  in 


16  THE    HEAD    AND    NECK 

thickness  from  2  to  5  mm.  (A  to  I  of  an  inch). 
In  the  vault  the  bony  wall  is  thicker,  varying 
from  5  to  10  mm.  (£  to  f  of  an  inch).  (See 
p.  30.) 

The  zygoma  may  be  broken  by  direct  or  in- 
direct violence.  In  the  latter  case  the  violence  is 
such  as  tends  to  thrust  the  upper  jaw  or  malar 
bone  backwards.  When  due  to  direct  violence,  a 
fragment  may  be  driven  into  the  temporal  muscle, 
and  much  pain  caused  in  moving  the  jaw.  In 
ordinary  cases  there  is  little  or  no  displacement, 
since  to  both  fragments  the  temporal  fascia  is 
attached  above  and  the  masseter  below.  The  zy- 
goma serves  as  a  most  useful  guide  to  the  position 
of  deep  parts.  Its  upper  border,  in  its  posterior 
three-fourths,  corresponds  to  the  floor  of  the  mid- 
dle fossa  of  the  skull,  and  marks  the  lower  border 
of  the  temporal  lobe  of  the  brain  which  lies  in 
that  fossa  (Fig.  4) ;  the  articular  tubercle,  felt 
so  plainly  near  its  root,  marks  the  point  at  which 
the  middle  meningeal  artery  perforates  the  base 
of  the  skull  by  the  foramen  spinosum  (Fig.  3), 
and  also  the  position  of  the  semilunar  or  Gasserian 
ganglion  (Fig.  32,  p.  131) ;  the  zygomatic  tubercle 
(postglenoid  spine),  which  bounds  the  mandibular 
fossa  posteriorly,  is  directly  over  the  carotid  canal 
(S.  Scott). 


CHAPTER    II 
THE    BONY   VAULT    OF   THE    CRANIUM 

Position  of  the  sutures.  —  The  bregma,  or 
point  of  junction  of  the  coronal  and  sagittal 
sutures,  is  in  a  line  drawn  vertically  upwards  from 
a  point  just  in  front  of  the  external  auditory 
meatus,  the  head  being  in  normal  position  (Fig.  3). 
The  lambda,  or  point  of  junction  of  the  lambdoid 
and  sagittal  sutures,  lies  in  the  middle  line,  about 
2j-  inches  above  the  occipital  protuberance  (Fig.  3). 
The  lambdoid  suture  is  fairly  represented  by  the 
upper  two-thirds  of  a  line  drawn  from  the  lambda 
to  the  apex  of  the  mastoid  process  on  either  side. 
The  coronal  suture  lies  along  a  line  drawn  from 
the  bregma  to  the  middle  of  the  zygomatic  arch. 
On  this  line,  at  a  spot  about  1^  inches  behind 
and  ^  an  inch  above  the  fronto-malar  (fronto- 
zygomatic)  junction,  is  the  pterion,  the  region 
where  four  bones  meet,  viz.  the  squama  of  the 
temporal,  the  great  wing  of  the  sphenoid,  the 
frontal  and  parietal  bones  (Fig.  3).  The  summit 
of  the  squamous  suture  is  If  inches  above  the 
zygoma. 

In  the  normal  subject  all  traces  of  the  fou- 
taiielles  and  other  unossified  parts  of  the  skull 
(Fig.  6)  disappear  before  the  age  of  2  years. 
The  frontal  or  anterior  fontanelle  is  the  last  to 
close,  while  the  occipital  or  posterior  is  already 
filled  at  the  time  of  birth.  It  is  through  or  near 
the  frontal  fontanelle  that  the  ventricles  are  usually 
aspirated  in  cases  of  hydrocephalus.  The  needle 
is  either  entered  at  the  sides  of  the  fontanelle 
at  a  sufficient  distance  from  the  middle  line  to 
avoid  the  longitudinal  sinus,  or  is  introduced 
17 


18  THE    HEAD    AND   NECK  [CHAP. 

through  the  coronal  suture  at  some  spot  other 
than  its  middle  point.  It  may  be  noted  that 
in  severe  hydrocephalus  the  coronal  and  other 
sutures  of  the  vault  are  widely  opened. 

The  condition  known  as  craiiiotabes,  a  con- 
dition assigned  by  some  to  rickets  and  by  others 
to  inherited  syphilis,  is  usually  met  with  in  the 
upper  or  tabular  part  of  the  occipital  bone, 
and  in  the  adjacent  parts  of  the  parietal  bones, 
but  especially  in  the  posterior  inferior  angles 
of  these  bones.  In  this  condition  the  bone  is 
greatly  thinned  in  spots,  and  its  tissue  so  reduced 
that  the  affected  district  feels  to  the  finger  as  if 
occupied  by  parchment,  or,  as  some  suggest,  by 
cartridge  paper.  The  thinning  is  mainly  at  the 
expense  of  the  inner  table  and  diploe.  The  pits 
are  situated  over  the  impressions  of  early-formed 
convolutions.  It  is,  on  the  other  hand,  about  the 
site  of  the  frontal  or  anterior  fontanelle  that  cer- 
tain osseous  deposits  are  met  with  on  the  surface 
of  the  skull  in  some  cases  of  hereditary  syphilis 
(Parrot).  These  deposits  appear  as  rounded  ele- 
vations of  porous  bone  situated  upon  the  frontal 
and  parietal  bones,  where  they  meet  in  the  middle 
line.  The  bosses  are  separated  by  a  crucial  de- 
pression represented  by  the  frontal  and  sagittal 
sutures  on  the  one  hand  and  the  coronal  suture  on 
the  other.  They  have  been  termed  "  natiform  " 
elevations  by  M.  Parrot  from  their  supposed  resem- 
blance, when  viewed  collectively,  to  the  nates.  To 
the  English  mind  they  would  rather  suggest  the 
outlines  of  a  "hot-cross  bun." 

It  is  necessary  to  refer  to  the  development  of 
the  skull,  in  order  to  render  intelligible  certain 
conditions  (for  the  most  part  those  of  congenital 
malformation)  that  are  not  infrequently  met  with. 
Speaking  generally,  it  may  be  said  that  the  base  of 
the  skull  is  developed  in  cartilage,  and  the  vault 
in  membrane.  The  parts  actually  formed  in  mem- 
brane are  represented  in  the  completed  skull  by 
the  frontal  and  parietal  bones,  the  squamo-zygo- 
matic  part  of  the  temporal  bone,  and  the  greater 


n]  MENINGOGELE  19 

part  of  the  tabular  portion  of  the  occipital  bone. 
The  distinction  between  these  two  parts  of  the 
skull  is  often  rendered  very  marked  by  disease. 
Thus  there  are,  in  the  museum  of  the  Royal  College 
of  Surgeons,  the  skulls  of  some  young  lions  that 
were  born  in  a  menagerie,  and  that,  in  consequence 
of  malnutrition,  developed  certain  changes  in 
their  bones..  A  great  part  of  each  of  these  skulls 
shows  considerable  thickening,  the  bone  being  con- 
verted into  a  porous  structure ;  and  it  is  remark- 
able to  note  that  these  changes  are  limited  to  such 
parts  of  the  skull  as  are  formed  in  membrane,  the 
base  remaining  free.  In  hydrocephaly  it  is  only 
the  bones  formed  in  membrane  which  are  unduly 
expanded.  On  the  other  hand,  in  the  condition 
known  as  achondroplasia  the  basal  or  cartilaginous 
parts  of  the  skull  are  strangely  arrested  in  their 
growth,  while  there  is  a  compensatory  overgrowth 
of  the  membrane-formed  elements. 

Among  the  more  common  of  the  gross  malforma- 
tions of  the  skull  also  is  one  that  shows  entire 
absence  of  all  that  part  of  the  cranium  that  is 
formed  in  membrane,  while  the  base,  or  cartila- 
ginous part,  is  more  or  less  perfectly  developed — 
the  condition  of  anencephaly. 

Meningocele  is  the  name  given  to  a  con- 
genital tumour  that  consists  of  a  protrusion  of 
a  part  of  the  cerebral  membranes  through  a 
gap  in  an  imperfectly  developed  skull.  When 
the  protrusion  contains  brain,  it  is  called  an 
encephalocele;  and  when  that  protruded  brain 
is  distended  by  an  accumulation  of  fluid  within 
the  ventricles,  it  is  called  hydrencephalocele. 
These  protrusions  are  most  often  met  with  in 
the  occipital  bone,  and  next  in  frequency  in 
the  fronto-nasal  suture,  while  in  rarer  cases 
they  have  been  met  with  in  the  lambdoid, 
sagittal,  and  other  sutures,  and  have  projected 
through  normal  and  abnormal  fissures  at  the 
base  of  the  skull  into  the  orbit,  nose,  and 
mouth.  Their  frequency  in  the  occipital  bone 
may  be  in  some  degree  explained  by  a  refer- 


20  THE    HEAD    AND    NECK  [CHAP. 

ence  to  the  development  of  that  part.  This 
bone  at  birth  consists  of  four  separate  parts 
(Fig.  5),  a  basilar,  two  condylic,  and  a  tabular 
or  expanded  part.  In  the  tabular  part,  about 
the  seventh  week  of  foetal  life  four  nuclei  appear, 
an  upper  and  a  lower  pair. 
^E^fiK^k^  These  nuclei  are  to  some  extent 

separated  by  fissures  running 
inwards  from  the  four  angles 
of  the  bone  to  meet  at  the 
occipital  protuberance.  The 
gap  running  up  in  the  median 
line  from  the  inferior  angle 
at  the  foramen  magnum  to 
the  occipital  protuberance  is 
especially  distinct  (the  tem- 
porary occipital  fontanelle  of 
Sutton).  It  exists  from  the 
beginning  of  the  third  to  the 
Fig.  5.— The  occi-  end  of  the  fourth  month  of 
pital  bone  at  birth,  intra-uterine  life.  Meningo- 
celes  of  the  occiput  are 
always  in  the  middle  line,  and  the  protrusion 
probably  occurs  through  this  gap.  The  gap  associ- 
ated with  meningocele  may  extend  through  the 
whole  vertical  length,  of  the  occipital  bone,  and 
very  commonly  opens  up  the  foramen  magnum. 
The  lateral  or  transverse  fissures  divide  the  bone 
into  two  parts.  The  upper  part  is  developed  from 
membrane,  the  lower  part  from  cartilage.  The 
lateral  fissures  may  persist,  and  may  simulate  frac- 
tures, for  which  they  have,  indeed,  been  mistaken  ; 
as  a  rare  anomaly  they  may  be  so  complete  as 
entirely  to  separate  the  highest  part  of  the 
occipital  bone  from  the  remainder. 

Parietal  fissures — In  the  developing  parie- 
tal bone,  fibres  concerned  in  ossification  radiate 
towards  the  periphery  from  two  nuclei  about  the 
centre  of  the  bone.  An  interfibrillar  space,  larger 
than  the  rest,  is  seen  about  the  fifth  month  to 
separate  the  loose  osseous  fibres  which  abut  on  the 
posterior  part  of  the  sagittal  border  from  the 


II] 


SUTURAL  BONES 


stronger  fibres  which  form  the  rest  of  this  border 
(Pozzi).  This  is  the  parietal  fissure.  It  usually 
closes  and  leaves  no  trace,  but  it  may  persist 
in  part  as  a  suture-like  fissure,  and  be  mistaken 
for  a  fracture.  If  the  fissure  persists  equally  on 
the  two  sides  an  elongated  lozenge-shaped  gap  is 
left,  the  sagittal  fontanelle  (Fig.  6).  It  is  situate 
about  an  inch  in  front  of  the  lambda,  and  occurs  in 
over  4  per  cent,  of  newly  born  children  (Lea).  The 
parietal  foramina  are  remains  of  this  interval. 

Suf ural  or  Wormian  bones.— These  irregu- 
lar bones  may  be  mistaken  for  fragments  produced 
by  fracture.  They  are  most  usually  met  with  in 
the  lambdoid  suture.  One  sutural  bone  deserves 
special  notice,  as  it  may  be  met  with  in  trephining 
over  the  middle  meningeal  artery.  It  exists  be- 


/IETOPIC  SUTURE 
__  FRONTAL  EMINENCE 

..BREQMATIC  Fb/ITANELLE 
..CORONAL  SUTUR& 

...SAQITTAL  SUTURE 


..PARIETAL 

_  5AC I TTA L  fO/1  TAM  E LLE 
-..UMBDOIDALfO/ITArtELLE 

.I/ITER-PARIETAL 

5UPRA-OCCIPITAL 


Fig.  6. — Skull  of  newly  born  child,  from  above. 

tween  the  anterior  inferior  angle  of  the  parietal 
bone  and  the  great  wing  of  the  sphenoid.  It  is 
scale-like,  and  gives  the  impression  that  the  tip 
of  the  great  wing  has  been  separated.  It  is  known 
as  the  epipteric  bone. 

Wecrosis  is  fairly  common  on  the  vault  of 
the  skull,  and  most  often  attacks  the  frontal 
and  parietal  bones,  while,  for  reasons  that 


22  THE    HEAD    AND    NECK  [CHAP. 

are  not  very  obvious,  it  is  rare  in  the  occi- 
pital bone.  The  external  table  is  frequently 
necrosed  alone,  it  being  more  exposed  to  injury 
and  less  amply  supplied  with  blood  than  is 
the  internal  table.  From  the  converse  of  these 
reasons  it  happens  that  necrosis  of  the  internal 
table  alone  is  but  rarely  met  with.  Necrosis  in- 
volving the  entire  thickness  of  the  bone  may  prove 
very  extensive,  and  in  a  case  reported  by  Saviard 
practically  the  whole  of  the  cranial  vault  necrosed 
and  came  away.  The  patient  was  a  woman,  and 
the  primary  cause  of  the  mischief  was  a  fall  upon 
the  head  when  drunk. 

Necrosis  of  the  skull,  as  well  as  caries  of  the 
part,  is  attended  by  certain  special  dangers  that  de- 
pend upon  the  anatomical  relations  of  the  cranial 
bones.  Thus,  when  the  whole  thickness  of  the  skull 
is  involved  by  disease,  or  when  the  inner  table  is 
especially  attacked,  a  collection  of  pus  may  form 
between  the  dura  mater  and  the  affected  bone,  and 
may  produce  compression  of  the  brain.  When  the 
diploic  tissue  is  implicated,  the  veins  of  that  part 
may  become  thrombosed,  or  may  be  the  seat  of  a 
suppurative  phlebitis.  The  mischief  thus  com- 
menced may  spread,  the  great  intracranial  sinuses 
may  be  closed  by  thrombus,  or  septic  matter  may 
be  conveyed  into  the  general  circulation  and  lead 
to  the  development  of  pyaemia. 

Mere  local  extension  may  also  cause  meningitis. 
In  cases  of  necrosis  of  the  external  table  the  growth 
of  granulation  tissue  from  the  exposed  and  vascu- 
lar diploe  p^lays  a  very  important  part  in  aiding 
the  exfoliation  of  the  lamella  of  dead  bone. 

Fractures  of  the  skull. — It  is  not  easy  ac- 
tually to  fracture  the  skull  of  a  young  infant.  The 
skull  as  a  whole  at  this  age  is  imperfectly  ossified, 
the  sutures  are  wide,  and  between  the  bones  there 
is  much  cartilage  and  membrane.  Moreover,  the 
bones  themselves  in  early  life  are  elastic,  and  com- 
paratively soft  and  yielding.  If  a  blow  be  inflicted 
upon  the  vault  in  a  young  child  the  most  probable 
effect,  so  far  as  the  bone  itself  is  concerned,  is  an 


n]  FRACTURES   OF  THE  SKULL  23 

indenting  or  bulging-in  of  that  bone  unassociated 
with  a  fracture  in  the  ordinary  sense.  In  this  par- 
ticular relation  the  skull  of  an  infant  is  to  that  of 
an  old  man  as  a  cranium  of  thin  tin  would  be  to  a 
cranium  of  strong  earthenware.  The  yielding  char- 
acter of  the  young  child's  skull  is  well  illustrated 
by  the  gross  deformity  of  the  head  that  certain 
Indian  tribes  produce  in  their  offspring  by  apply- 
ing tight  bandages  to  the  part  in  infancy.  In  the 
Royal  College  of  Surgeons  museum  are  many 
skulls  of"  flat-headed  JJ  In.dians,  that  show  to  what 
an  extreme  this  artificial  deformity  may  be  carried. 
Gueniot  also  asserts  that  much  deformity  of  the 
head  may  be  produced  in  infants  by  the  practice 
of  allowing  them  always  to  lie  upon  one  side  of 
the  body.  Here  the  deforming  agent  is  simply  the 
weight  of  the  brain. 

Even  in  adults  the  skull  is  much  less  brittle 
than  is  commonly  supposed,  and  notions  derived 
from  the  study  of  dried  specimens  are  apt  to  be 
erroneous.  During  life  a  sharp  knife  properly 
directed  may  be  driven  through  the  cranial  vault  so 
as  to  cause  only  a  simple  perforating  wound  with- 
out splintering,  and  without  fracture  of  the  bone 
beyond  the  puncture.  Such  a  wound  may  be  as 
cleanly  cut  as  a  wound  through  thick  leather,  and 
a  specimen  in  the  London  Hospital  museum  serves 
well  to  illustrate  this.  A  case  reported  in  the 
Lancet  for  1881  affords  a  strange  instance  of  a  knife 
penetrating  the  skull  without  apparently  splinter- 
ing the  bone.  m  A  man  wishing  to  commit  suicide 
placed  the  point  of  a  dagger  against  the  skull  in 
the  upper  frontal  region,  and  then  drove  it  well 
into  the  brain  by  a  blow  from  a  mallet.  He  ex- 
pected to  fall  dead,  and  was  disappointed  to  find 
that  no  phenomena  of  interest  developed.  He  then 
drove  the  dagger  farther  in  by  some  dozen  blows 
with  the  mallet,  until  the  blade,  which  was  four 
inches  long,  was  brought  to  a  standstill.  The 
dagger  was  removed  with  great  difficulty ;  the 
patient  never  lost  consciousness,  and  recovered 
without  a  symptom. 


24  THE    HEAD    AND    NEGK  [CHAP. 

The  following  anatomical  conditions  tend  to 
minimize  the  effects  of  violence  as  applied  to  tho 
skull  :  the  density  of  the  scalp  and  its  great 
mobility  ;  the  dome-like  arrangement  of  the  vault ; 
the  number  of  the  bones  that  compose  the  head, 
and  the  tendency  of  the  violence  to  be  broken  up 
amongst  the  many  segments  ;  the  sutures  which 
interrupt  the  continuity  of  any  given  force,  and  the 
sutural  membrane,  which  acts  as  a  kind  of  linear 
buffer ;  the  mobility  of  the  head  upon  the  spine ; 
and  the  elasticity  of  the  cranial  bones  themselves. 

The  skull  is  further  strengthened  by  the  pre- 
sence of  six  buttresses  or  pillars  at  the  junction  of 
the  vault  and  base.  Two  of  these  are  lateral,  the 
orbito-sphenoid  anteriorly  and  the  petro-mastoid 
posteriorly,  while  the  fronto-nasal  and  occipital 
strengthen  the  anterior  and  posterior  ends  of  the 
skull. 

In  children  the  membranous  layer  between  the 
sutures  is  of  considerable  thickness,  but  as  age 
advances  this  membrane  disappears  and  the  bones 
tend  to  fuse  together  (synostosis).  The  sutures 
begin  to  be  obliterated  about  the  age  of  40,  the 
change  commencing  on  the  inner  aspect  of  the 
suture,  and  appearing  first  in  the  sagittal  suture, 
then  in  the  coronal  and  lambdoid,  and  last  in 
the  squamous.  As  age  advances,  moreover,  the 
skull  bones  become  thicker  owing  to  a  deposit  over 
the  inner  table  to  replace  the  diminishing  brain, 
and  lose  much  of  their  elasticity.  They  are,  there- 
fore, more  readily  fractured  in  the  aged  than  in 
the  young. 

As  a  rule,  in  fracture,  the  entire  thickness  of  the 
bone  is  involved  ;  but  the  external  table  alone  may 
be  broken,  and  may  even  be  alone  depressed,  being 
driven  into  the  diploe,  or,  in  the  case  of  the  lower 
frontal  region,  into  the  frontal  sinus.  The  internal 
table  may  be  broken  without  a  corresponding  frac- 
ture in  the  outer  plate ;  and  in  nearly  all  cases 
of  complete  fracture,  especially  in  such  as  are  at- 
tended with  depression,  the  internal  table  shows 
more  extensive  splintering  than  does  the  external. 


n]  jj    -p    FRACTURES   OF  THE  SKULL  25 

There  are  many  reasons  for  this.  The  internal 
plate  is  not  only  thinner  than  the  external,  but  is 
so  much  more  brittle  as  to  receive  the  name  of  the 
" vitreous  table."  A  force  applied  to  the  external 
table  may  be  extremely  limited,  and  produce,  as  in 


a  sabre  cut,  but  a  limited  lesion.  As  the  force, 
however,  travels  through  the  diploe  it  becomes 
broken  up,  and  reaches  the  inner  plate  as  a  much 
more  diffused  form  of  violence.  This  is  especially 
the  case  when  parts  of  the  outer  table  are  driven 
in.  Then,  again,  the  internal  plate  is  a  part  of  a 


Fig.  8. 

smaller  curve  than  is  the  external  plate  ;  and, 
lastly,  Agnew  assigns  a  reason  for  the  greater  vul- 
nerability of  the  inner  plate  that  has  reference 
to  the  general  yielding  of  the  bone.  In  Fig.  7,  AB 
represents  a  section  of  a  part  of  the  vault  through 
both  tables,  and  c  D  and  E  F  two  vertical  and  paral- 
lel lines.  Now,  if  force  be  applied  to  the  vault 


26  THE    HEAD    AND    NECK  [CHAP. 

between  these  parallel  lines,  the  ends  of  the  arch, 
A  B,  will  tend  to  become  separated,  and  the  whole 
arch,  yielding,  will  tend  to  assume  the  curve  shown 
in  Fig.  8.  In  such  case,  the  lines  CD  and  EF  will 
converge  above  and  diverge  below  (Fig.  8),  so  that 
the  violence  would  tend  to  force  the  bone  particles 
together  at  the  outer  table  and  asunder  at  the 
inner  table. 

Fractures  of  the  vault  are  due  to  direct  vio- 
lence. The  construction  of  the  skull  is  such  that 
the  fracturing  force  is  resisted  in  many  ways. 
(1)  When  a  blow  is  received  on  the  vertex  in  the 
parietal  region,  the  force  tends  to  drive  the  upper 
borders  of  the  two  parietal  bones  inwards.  Such 
driving-in  of  these  borders  must  be  associated  with 
a  corresponding  outward  movement  of  the  inferior 
borders.  This  latter  movement  is  forcibly  resisted 
by  the  squampus  bone  and  the  great  wing  of  the 
sphenoid,  which  overlap  the  lower  edge  of  the 
parietal  bone.  Moreover,  the  force  transmitted  to 
the  squamous  bone  is  passed  on  to  the  zygomatic 
arch,  which  takes  its  support  from  the  superior 
maxillary  and  frontal  bones.  This  arch  then  acts  as 
a  second  resisting  buttress,  and  this  transmission 
of  force  from  the  vertex  to  the  facial  bones  is  said 
to  be  illustrated  by  the  pain  often  felt  in  the  face 
after  blows  upon  the  top  of  the  head.  (2)  If  the 
upper  part  of  the  frontal  bone  be  struck,  the  force 
is  at  once  transmitted  to  the  parietal  bones,  be- 
cause the*  upper  part  of  the  frontal  bone  (owing  to 
the  manner  in  which  its  border  is  bevelled)  actu- 
ally rests  upon  the  two  parietal  bones ;  so  the  same 
resistance  is  again  called  into  action.  If  there  be  any 
tendency  for  the  inferior  parts  of  the  bone  to  move 
outwards,  as  would  certainly  be  the  case  while  the 
mid-frontal  suture  existed,  such  movement  ^  would 
be  resisted  by  the  great  wings  of  the  sphenoid  and 
by  the  anterior  inferior  angles  of  the  parietal  bones 
which  embrace  or  overlap  these  parts  of  the 
frontal.  Thus  it  will  be  seen  that  much  depends 
upon  the  manner  in  which  the  corresponding  edges 
of  the  frontal  and  parietal  bones  are  bevelled.  (3) 


n]  FRACTURES   OF   BASE   OF  SKULL  27 

Blows  upon  the  occiput  are  less  distinctly  pro- 
vided for,  and  it  must  be  owned  that  a  by  no 
means  heavy  fall  is  sufficient  to  break  this  bone. 
It  must  receive,  however,  much  protection  from 
its  connexions  with  the  two  parietal  and  tem- 
poral bones,  and  from  its  articulation  with  the 
elastic  vertebral  column. 

Fractures  of  the  base  of  the  skull  may  be  due 
to  (1)  direct  or  (2)  indirect  violence,  or,  most 
commonly  of  all,  to  (3)  extension  of  a  fracture 
from  the  vault.  (1)  The  base  has  been  fractured 
by  direct  violence  due  to  foreign  bodies  thrust 
through  the  nasal  roof,  through  the  orbital  roof, 
and  through  the  base  as  it  presents  in  the  pharynx. 
The  posterior  fossa  can  also  be  fractured  by  vio- 
lence applied  to  the  nape  of  the  neck.  (2)  Of  frac- 
tures by  indirect  violence  the  following  examples 
may  be  given :  Blows  applied  to  the  lower  part  of 
the  frontal  bone  have  been  associated  with  no 
lesion  other  than  a  fracture  of  the  cribriform 
plate  or  of  the  orbital  part  of  the  frontal, 
these  parts  being  much  disposed  to  fracture 
on  account  of  their  extreme  tenuity.  In  8G 
cases  of  fracture  of  the  base  of  the  skull,  the 
orbital  roof  was  involved  in  79,  the  optic  foramina 
in  63,  and  the  cribriform  plates  in  nearly  all  (Raw- 
ling).  _  In  falls  upon  the  chin,  the  condyle  of  the 
lower  jaw  has  been  so  violently  driven  against  the 
glenoid  cavity  as  to  fracture  the  middle  fossa  of 
the  skull.  The  force  of  a  "  knock-out "  blow  applied 
to  the  point  of  the  chin  produces  concussion  of  the 
brain  without  fracture  of  the  skull.  When  the  body 
in  falling  has  alighted  upon  the  feet,  knees,  or  but- 
tocks, the  force  has  been  transmitted  along  the 
vertebral  column,  and  has  led  to  fracture  o.f  the 
base  in  the  occipital  region.  Such  accidents  are 
most  apt  to  occur  when  the  spine  is  kept  rigid  by 
muscular  action,  and  the  mechanism  involved  is 
precisely  similar  to  that  whereby  the  head  of  a 
broom  is  driven  more  firmly  on  to  the^  brooms-handle 
by  striking  the  extreme  end  of  the  stick  against  the 
ground.  The  theory  that  the  base  is  often  broken 


28  THE    HEAD    AND    NEOK  [CHAP. 

by  contre-coup  is  pretty  generally  abandoned, 
though  there  are  a  few  cases  that  appear  to  support 
the  suggestion.  Such  a  case  was  recorded  by  Sir 
J.  Hutchinson,  and  in  it  a  fracture  of  the  occipital 
bone  was  associated  with  a  like  lesion  in  the  cribri- 
form plate,  the  intervening  part  of  the  skull  being 
uninjured.  (3)  Fractures  of  the  vault,  and  especi- 
ally linear  fractures  due  to  such  diffused  violence 
as  obtains  in  a  fall  upon  the  head,  are  very  apt  to 
spread  to  the  base.  In  so  spreading  they  reach  the 
base  by  the  shortest  possible  route,  and  without 
any  regard  to  the  sutures  encountered  or  to  the 
density  of  the  bones  involved.  Thus,  fractures  of 
the  frontal  region  of  the  vault  spread  to  the  an- 
terior fossa  of  the  base,  those  of  the  parietal  region 
to  the  middle  fossa,  and  those  of  the  occipital 
region  to  the  posterior  fossa.  To  this  rule  there  are 
but  few  exceptions.  To  indicate  more  precisely 
the  exact  bones  involved  in  these  three  districts, 
P.  Hewett  has  divided  the  skull  into  three  zones. 
The  anterior  zone  includes  the  frontal,  the  upper 
part  of  the  ethmoid,  and  the  f ronto-sphenoid ;  the 
middle,  the  parietals,  the  squamous  and  anterior 
part  of  the  petrous  of  the  temporals,  and  the 
greater  part  of  the  basi-sphenoid ;  and  the  pos- 
terior, the  occipital,  the  mastoid,  the  posterior 
part  of  the  petrous  bone,  with  a  small  part  of 
the  body  of  the  sphenoid. 

In  all  fractures  of  the  base  there  is  usually  a 
discharge  of  blood  and  of  cerebro-spinal  fluid  ex- 
ternally. (1)  In  fractures  of  the  anterior  fossa  the 
blood  usually  escapes  from  the  nose,  and  is  derived 
from  the  meningeal  and  ethmoidal  vessels,  or  in 
greater  degree  probably  from  the  torn  mucous  lin- 
ing of  the  nasal  roof.  To  allow  of  the  escape  of 
cerebro-spinal  fluid  from  the  nose,  there  must  be, 
in^addition  to  the  fracture  in  the  nasal  roof,  a  lacer- 
ation of  the  mucous  membrane  below  that  fracture, 
and  of  the  sheaths  of  the  olfactory  nerves  which  are 
derived  from  the  dura  mater  and  arachnoid.  A 
profuse  discharge  of  cerebro-spinal  fluid  may  take 
place  through  the  nasal  mucous  membrane  inde- 


n]  SEPARATION   OF  SUTURES  29 

pendently  of  inj  ury.  The  discharge  probably  occurs 
along  the  sheaths  of  the  olfactory  nerves,  and 
is  caused  by  a  lessened  absorption  or  increased 
secretion  of  cerebro-spinal  fluid.  In  many  cases  of 
fracture  in  the  frontal  region,  blood  finds  its  way 
into  the  orbit,  and  appears  beneath  the  conjunctiva. 
(2)  When  the  middle  fossa  is  involved,  the  blood 
escapes  from  the  external  auditory  meatus,  through 
a  rupture  in  the  tympanic  membrane,  and  is  de- 
rived from  the  vessels  of  the  tympanum  and  its 
membrane,  or  from  an  intracranial  extravasation, 
and  in  some  cases  from  a  rupture  of  the  cavernous 
or  petrosal  sinuses.  The  blood  may  follow  the 
Eustachian  tube,  and  may  escape  from  the  nose  or 
mouth,  or  be  swallowed  and  subsequently  vomited. 
To  allow  of  the  escape  of  cerebro-spinal  fluid  by  the 
ear  ("the  serous  discharge  "),  (a)  the  fracture  must 
have  passed  across  the  internal  auditory  meatus  ; 
(6)  the  tubular  prolongation  of  the  membranes  in 
that  meatus  must  have  been  torn ;  (c)  there  must 
be  a  communication  between  the  internal  ear  and 
the  tympanum  ;  and  (d)  the  membrana  tympani 
must  have  been  lacerated.  (3)  In  fractures  of  the 
posterior  fossa  an  extravasation  of  blood  may  ap 
pear  about  the  mastoid  process  or  at  the  nape  of 
the  neck,  or  may  even  extend  into  the  cervical  region. 

It  may  be  added  that  in  compound  fractures 
of  the  vault  associated  with  tearing  of  the  dura 
mater  and  arachnoid,  an  escape  of  cerebro-spinal 
fluid  has  in  a  few  rare  instances  been  noted.  After 
simple  fracture  of  the  vault  in  children  a  swelling 
may  form  at  the  injured  part  which  fluctuates,  be- 
comes tenser  when  the  patient  cries,  and  may  pos- 
sibly pulsate  synchronously  with  the  brain.  Such 
swellings  are  due  to  a  collection  of  cerebro-spinal 
fluid  beneath  the  scalp,  and  indicate  a  coincident 
rupture  of  the  brain  membranes. 

Separation  of*  sutures.— This  condition,  as 
the  result  of  injury,  is  practically  restricted  to  the 
young  skull.  In  later  life,  force  applied  at  the 
site  of  an  obliterated  suture  may  cause  a  frac- 
ture, which  accurately  follows  the  old  suture  line. 


30  THE    HEAD    AND    NECK  [CUAP. 

Separation  of  the  sutures,  independent  of  fracture, 
is  very  rare  in  the  adult  skull.  In  the  few  instances 
of  such  a  condition  the  temporal  bone  has  usually 
been  the  one  displaced  and  the  separation  noted 
at  the  squamous  suture.  When  associated  with 
fracture,  the  coronal  and  sagittal  sutures  are  those 
most  frequently  separated,  and  the  next  in  fre- 
quency is  the  lambdoid. 

The  thickness  of  the  skull-cap  varies 
greatly,  not  only  in  different  parts  of  the  same 
skull,  but  also  in  corresponding  parts  in  different 
individuals.  The  average  thickness  is  5  mm.  (I  of 
an  inch).  It  varies  with  age:  at  birth  the 
parietal  is  little  more  than  1  mm.  (2V  of  an 
inch) ;  at  three  years  diploe  appear,  marking  off 
the  inner  from  the  outer  table  of  the  skull;  in 
old  people  the  parietal  bone  varies  in  thickness 
from  5-10  mm.  (i-f  of  an  inch).  The  thickest 
parts  are  at  the  occipital  protuberance  (where  the 
section  may  measure  12  or  13  mm.),  the  mastoid 
process,  and  the  lower  part  of  the  frontal  bone. 
The  bone  over  the  inferior  occipital  f ossse  and  orbit 
is  very  thin,  while  it  is  thinnest  over  the  squamous 
bone.  Here  the  bone  may  be  no  thicker  in  parts 
than  a  visiting  card,  and  appear  as  a  translucent 
area  in  an  X-ray  photograph.  The  skull  is  also 
thinned  over  the  sinuses  and  grooves  for  the 
meningeal  vessels.  It  is  especially  thin  over  the 
anterior  inferior  angle  of  the  parietal  bone.  It 
is  important  to  remember  in  trephining  that  the 
inner  table  is  not  always  parallel  with  the  outer. 

Craniectomy.  —  This  operation  is  carried  out 
in  cases  of  microcephaly  in  infants  and  chil- 
dren. It  consists  in  the  removal  of  a  strip  of  bone 
from  the  vertex  of  the  skull  so  as  to  give  to  the 
brain,  as  an  American  author  expresses  it,  "  more 
elbow  room."  The  operation  presumes  that  the 
arrest  of  growth  in  the  brain  *is  due  to  a  retarded 
growth  of  the  skull,  but  all  the  evidence  at  our  dis- 
posal points  to  the  arrest  in  the  development  of 
the  brain  as  the  primary  lesion,  the  condition  of 
the  skull  being  a  consequence.  In  hydrocephaly 


n]  X-RAY   EXAMINATION  31 

the  skull  is  seen  to  respond  readily  to  the  quick 
expansion  of  the  brain ;  if  the  growth  of  the  brain 
is  arrested,  the  skull  remains  small. 

X-ray  exami nation  of  the  temporal 
region. — It  is  frequently  necessary  to  examine  the 
temporal  region  of  the  skull  to  discover  the  condi- 
tion of  certain  deep-seated  intracranial  structures. 
To  find  the  position  of  such  structures,  certain 
easily-found  surface-points  must  be  marked  by 
pellets  of  lead  in  order  that  they  may  serve  as 
guides.  The  most  convenient  and  reliable  guide- 
points  are  those  indicated  in  Fig.  9;  they  are — A, 
the  fronto-malar  (fronto-zygomatic)  notch; B,  the 
malar  angle;  D,  the  premeatal  pointy  on  the  root 
of  the  zygoma,  in  front  of  the  meatus,  behind 
the  mandibular  (glenoid)  fossa,  and  immediately 
above  the  postmandibular  (postglenoid)  spine; 
c,  a  point  on  the  upper  border  of  the  zygoma, 
midway  between  B  and  D  (midzygomatic  point). 
These  points  should  be  marked  on  both  sides  of 
the  skull,  and  the  corresponding  points  of  the 
two  sides  should  be  superimposed  when  the  skull 
is  examined  in  profile.  When  thus  examined,  the 
region  covered  by  the  two  temporal  muscles 
becomes  an  illuminated  area  owing  to  the  thin- 
ness of  the  bones  underlying  the  muscles.  The 
illuminated  area  is  subdivided  into  an  anterior 
or  frontal  fenestra  and  a  posterior  or  temporal 
fenestra  (Fig.  9)  by  the  fronto-temporal  pillar  of 
bone  which  carries  the  middle  meningeal  vessels 
and  marks  the  separation  of  the  frontal  from 
the  temporal  lobes  of  the  brain.  At  the  point 
where  trephining  is  usually  performed  for  me- 
ningeal haemorrhage — namely,  1-|  inches  behind 
and  ^  an  inch  above  the  fronto-malar  notch — the 
shadow  of  the  fronto-temporal  pillar  appears  to 
divide  into  two — an  anterior  horizontal  branch 
which  corresponds  to  the  roof  of  the  orbit  and 
is  situated  ^  an  inch  above  the  fronto-malar 
notch,  and  a  descending  branch  which  reaches 
the  upper  b9rder  of  the  zygoma  just  in  front 
of  c,  the  midzygomatic  point.  The  descending 


32 


THE    HEAD    AND    NECK 


[CHAP. 


branch  represents  the  anterior  wall  of  the  middle 
cranial  fossa,  the  spheno-orbital  septum.  It  de- 
scends |  of  an  inch  behind  the  temporal  border  of 
the  malar  bone.  It  will  thus  be  seen  that  between 
the  spheno-orbital  septum  behind,  the  temporal 
border  of  the  malar  in  front,  the  shadow  of  the 


TEMPORAL   Ft  IDG, 
ORBITAL 
FRONTO-MALAR 
SUTU, 


CORONAL.  SUTURE 
FRONTAL.   FENESTRA, 

FRONTO-TEMPORAL  PILLAR 


OPTIC  FORAMEN 

TEMPORAL  FENESTRA 
•3OUAM .  SUTURE 


PETROUS  SHADOW 

MASTO  -  PARIETAL 
I   .,     PILLAR 

I  LATERAL  S//VJ/3 


£THMOIDAL    SINUS 


INT.    AUD.MEAT. 

STOfD   Pf»OC. 
EXT.  At/0.  MEAT., 
POST.  OL£N. SPINE 
ARTIC. TUBERCLE 
SPHZNOIDAL  SINVS 


SPHENO-ORBITAL   WALL 


Fig.  9.— Structures  seen  in  the  temporal  region  when  the 
skull  is  examined  in  profile  by  means  of  X-rays. 

orbital  roof  above,  and  the  upper  border  of  the 
zygoma  below,  there  is  marked  out  a  very  dis- 
tinct retromalar  area  in  which  lie  the  middle 
and  posterior  ethmoidal  cells.  The  area  is  crossed 
from  behind  forwards,  and  below  the  level  of 
the  fronto-malar  notch,  by  two  lines,  the  lower 
of  which  corresponds  to  the  level  of  the  cribri- 
form plate,  and  the  upper  to  the  junction  between 


n]  X-RAY  EXAMINATION  33 

the  lateral  mass  of  the  ethmoid  and  the  orbital 
plate  of  the  frontal  bone.  At  the  lower  limit  of 
the  retromalar  area  lie  the  spheno-maxillary 
(pterygopalatine)  fossa,  the  spheno-maxillary  fis- 
sure, the  spheno-palatine  ganglion,  and  the  com- 
mencement of  the  infraorbital  nerve. 

Along  the  lower  border  of  the  temporal  fenestra 
appear  structures  of  the  utmost  consequence. 
Enumerating  these  from  before  backwards,  we 
note:  the  lesser  wing  of  the  sphenoid,  the 
pituitary  fossa  (fossa  hypophyseos),  crowned 
anteriorly  by  the  anterior  clinoid  process,  and 
posteriorly  by  the  dorsum  sellse  and  posterior 
clinoid  processes.  Behind  the  dorsum  sellse  lies 
the  black  triangular  shadow  of  the  petrous  bone, 
ending  posteriorly  in  the  masto-parietal  pillar. 
The  floor  of  the  pituitary  fossa  lies  \  an  inch 
(12  mm.)  above  the  upper  border  of  the  zygoma,  its 
anterior  limit  lying  directly  above  the  midzygo- 
matic  point.  The  antero-posterior  diameter  of  the 
pituitary  fossa  is  normally  about  12  mm.  (^  an 
inch)  in  adults.  The  optic  foramen  lies  1^  inches 
(37  mm.)  behind  the  fronto-malar  notch,  and 
1  inch  (25  mm.)  above  the  upper  border  of  the 
zygoma.  The  premeatal  point  (see  Fig.  9)  marks 
the  hinder  aspect  of  the  basilar  process;  the 
internal  auditory  meatus  lies  |  an  inch  behind 
and  above  this  point;  the  external  auditory 
meatus  is  situated  immediately  behind  and  below 
it,  while  the  basion,  at  the  anterior  margin  of 
the  foramen  magnum,  lies  |  an  inch  below  and 
behind  this  point.  The  sphenoidal  sinus  lies 
below  and  in  front  of  the  pituitary  fossa. 


CHAPTER  III 
THE   CRANIAL    CONTENTS 

Membranes    of     the     IM.SIII. — The  dura  mater, 

from  its  toughness,  forms  an  excellent  protec- 
tion to  the  brain.  It  is  very  intimately  adherent 
to  the  bone  over  the  whole  of  the  base  of  the 
skull,  and  consequently  in  this  situation  extrava- 
sations between  the  membrane  and  the  bone  are 
scarcely  possible.  Over  the  vault  its  attachments 
are  comparatively  loose,  but  it  is  very  closely 
adherent  along  the  lines  of  the  sutures.  This  lax 
attachment  allows  large  hsemorrhagic  and  puru- 
lent extravasations  to  collect  between  the  dura 
mater  and  the  bone.  Such  extravasations  usually 
lead  to  compression  of  the  brain,  and  it  may  be 
noted  that  in  the  great  majority  of  all  cases  of 
compression  the  compressing  force  is  outside  the 
dura  mater.  Thus,  in  uncomplicated  cases  when 
symptoms  of  compression  come  on  at  the  time  of 
an  accident,  the  cause  is  probably  depressed  bone; 
when  they  appear  after  a  short  interval,  the  cause 
is  probably  extra vasated  blood  between  the  mem- 
brane and  the  bone;  and  when  a  long  interval 
(days  or  weeks)  has  elapsed  after  the  accident,  the 
cause  is  probably  a  collection  of  pus  in  the  same 
situation. 

Sir  C.  Bell  pointed  out  that  the  dura  mater  of 
the  vault  may  be  separated  from  the  bone  by  the 
vibration  produced  by  a  blow.  "Strike  the  skull 
of  a  subject  with  a  heavy  mallet;  on  dissecting  you 
find  the  dura  mater  to  be  shaken  from  the  skull  at 
the  point  struck.  Repeat  the  experiment  on  an- 
other subject,  and  inject  the  head  minutely  with 
size  injection,  and  you  will  find  a  clot  of  injection 
34 


MIDDLE  MENINGEAL  ARTERY  35 

lying  betwixt  the  skull  and  dura  mater  at  the  part 
struck,  and  having  an  exact  resemblance  to  the 
coagulum  found  after  violent  blows  on  the  head." 
Tillaux  has  demonstrated  that  the  adhesions  be- 
tween the  dura  mater  and  the  bone  are  particularly 
weak  in  the  temporal  fossae,  the  most  .usual  site  of 
meningeal  haemorrhage. 

When  blood  is  poured  out  between  the  dura 
mater  and  the  bone  in  cases  of  fracture,  the 
vessels  which  give  way  are  the  middle  me- 
niiigeal— much  more  frequently  the  companion 
veins  than  the  .artery.  The  veins  form  a  sinus 
round  the  artery  (Wood- Jones).  The  artery, 
having  passed  through  the  foramen  spinosum, 
divides  into  two  branches :  the  anterior,  the 
larger,  runs  upwards  across  the  anterior  inferior- 
angle  of  the  parietal  bone  and  ascends  the  vault 
a  short  distance  behind  the  coronal  suture; 
the  posterior  runs  backwards,  with  a  horizontal 
sweep  across  the  squamous  bone,  and  takes  the 
course  of  the  second  temporal  convolution.  (See 
Figs.  3,  4,  pp.  13,  15.) 

The  vessels  are  very  frequently  torn  as  they 
cross  the  anterior  angle  o<f  the  parietal  bone. 
There  are  many  reasons  for  this :  the  bone,  where 
grooved  by  the  vessels,  is  very  thin;  they  are 
often  so  embedded  in  the  bone  that  fracture  with- 
out laceration  O'f  the  vessel  would  hardly  be  pos- 
sible; and,,  lastly,  the  particular  region  of  the 
artery  is  a  part  of  the  skull  peculiarly  liable  to 
be  fractured.  Mr.  Jaeobson  shows  that  the  vessels 
(usually  the  veins  only)  may  be  ruptured  by  a 
force  that  does  not  fracture  the  skull,  but  merely 
leads  to  detachment  of  the  dura  mater.  Failing 
the  middle  meningeal,  the  most  frequent  source  of 
extra-meningeal  haemorrhage  is  the  lateral  sinus, 
for  reasons  that  will  be  obvious. 

Nerves  of  the  dura  mater.  —  The  dura 
mater  is  supplied  with  nerves.  The  chief  source 
is  from  the  fifth,  but  minor  supplies  are  given 
off  by  the  tenth  and  twelfth  cranial  nerves.  Hence 
it  is  that  in  the  operation  of  trephining  there 


36  THE    HEAD    AND   NECK  [CHAP. 

is  a  marked  fall  of  blood-pressure  when  the 
membrane  is  scraped  or  cut  (H.  Tyrell'Gray  and 
L.  Parsons).  Many  forms  of  headache  are  due 
to  afferent  stimuli  reaching  the  vagal  or  tri- 
geminal  sensory  nuclei,  where  they  are  referred 
by  this  nerve  distribution  to  the  dura  mater 
(Gushing). 

Venous  sinuses. — The  flaccid-walled  cerebral 
veins,  which  are  compressed  with  each  pulsa- 
tion of  the  brain,  empty  into  the  venous  sinuses, 
rigid-walled  cavities  formed  between  the  outer  or 
periosteal  and  inner  or  supporting  layers  of  the 
dura  mater.  At  the  points  where  the  superior 
cerebral  veins  enter  the  superior  longitudinal 
sinus,  and  where  the  temporo-sphenoidal  and 
occipital  veins  join  the  lateral  siiius,  the  arach- 
noid, elsewhere  free  from  dura  mater,  is  firmly 
adherent  to  it.  From  a  surgical  point  of  view 
the  lateral  is  the  more  important  sinus;  and  as 
it  turns  downwards  beneath  the  mastoid  process 
it  comes  into  close  relationship  with  the  antrum 
and  cells  of  the  mastoid,  from  which  a  septic  con- 
dition may  spread  to  the  sinus,  setting  up  throm- 
bosis (see  Fig.  24,  p.  96).  The  lateral  sinus  is 
marked  out  by  taking  the  following  three  points 
(see  Fig.  3,  p.  13,  and  Fig.  4,  p.  15):  (1)  The 
inion,  (2)  the  asterion,  (3)  a  point  £  an  inch  behind 
the  lower  border  of  the  meatus.  When  these  three 
points  are  joined,  the  lateral  sinus  is  seen  to  be 
made  up  of  two  ^arts— a  horizontal,  which  gradu- 
ally ascends  as  it  passes  from  the  inion  to  the 
asterion;  and  a  vertical,  which  rapidly  descends 
from  the  asterion  to  the  postmeatal  point.  The 
sinus  is  10  mm.  wide.  The  lateral  sinus  escapes  from 
the  skull  to  form  the  internal  jugular  vein  in  line 
with  the  anterior  border  of  the  mastoid  process, 
but  -situated  deeply  beneath  the  parotid  gland 
(Fig.  3,  p.  13). 

A  line  drawn  over  the  vault  of  the  skull  from 
nasion  to  inion  marks  the  line  of  the  superior 
longitudinal  sinus.  Along  the  sinus  there  occur 
lateral  extensions  or  lacunae  (parasinoids)  into 


in]  VENOUS   SINUSES  37 

which  many  of  the  superior  cerebral  veins  open. 
These  lateral  extensions  are  found  along  all 
parts  of  the  superior  longitudinal  sinus,  but  the 
longest  and  most  important  are  the  parietal, 
which  cover  the  upper  parts  of  the  central  con- 
volutions (Percy  Sargent).  The  superior  longi- 
tudinal sinus  sometimes  becomes  occluded  by  the 
formation  of  a  thrombus;  in  that  case  the 
blood  has  to  find  its  way,  by  means  of  anastomotic 
channels,  from  the  superior  cerebral  veins  to  in- 
ferior cerebral  veins,  particularly  the  superficial 
Sylvian  vein,  which  ends  in  the  cavernous  sinus. 
In  the  majority  of  cases  the  superior  longitudinal 
ends  in  the  right  lateral  sinus,  which  is  hence 
commonly  larger  than  the  left.  The  cavernous 
sinus,  enclosing  the  internal  carotid  artery  and 
sixth  cranial  nerve,  with  the  third,  fourth,  and 
greater  part  of  the  fifth  embedded  in  its  wall,  is 
situated  on  the  body  of  the  sphenoid,  just  over  the 
sphenoidal  air  sinus,  from  which  septic  conditions 
may  extend  to  it,  giving  rise  to  thrombosis.  In 
such  cases  the  eyes  become  prominent  owing  to  the 
distension  of  the  ophthalmic  veins,  for  the  venous 
stream  from  the  orbit  flows  through  the  cavernous 
sinus  to  reach  the  lateral  sinus  and  jugular  vein  by 
means  of  the  superior  and  inferior  petrosal  sinuses. 
Tumours  of  the  pituitary  necessarily  compress  the 
cavernous  sinus.  The  relations  between  the  in- 
ternal carotid  artery  and  the  cavernous  sinus  are 
so  intimate  that  an  arterio-venous  aneurysm  has 
followed  injury  involving  these^ parts.  It  will  be 
seen  also  with  what  ease  this  sinus  could  become 
thrombosed  in  cases  of  inflammation  within  the 
orbit  by  the  extension  of  the  mischief  along  its 
great  tributaries,  the  two  ophthalmic  veins. 

Between  the  dura  mater  and  the  arachnoid  is 
the  siibdural  space,  which,  like  the  pleural 
cavity,  is  merely  a  potential  space,  for  in  health 
the  arachnoid  is  closely  applied  to  the  smooth 
inner  surface  of  the  dura  mater.  A  space  is  formed 
only  when  fluid,  blood,  or  pus  is  collected  between 
the  two  membranes  (Fig.  1,  p.  2).  The  subdural 


38  THE    HEAD    AND    NECK  [CHAP. 

space  contains  a  small  amount  of  fluid,  and  acts, 
like  the  pleural  and  peritoneal  sacs;  in  prevent- 
ing the  effects  of  friction  during  trie  pulsatory 
movements  of  the  brain. 

A  knowledge  of  the  sufoaraclmoid  space  is 
steadily  becoming  of  greater  surgical  importance. 
The  space  which  surrounds  the  spinal  cord  is  in 
direct  continuity  with  the  subarachnoid  spaces  of 
the  brain,  and  hence,  when  this  space  is  tapped 
in  the  lumbar  part  of  the  spinal  canal  (Fig.  151, 
p.  663),  the  fluid  situated  in  the  subarachnoid 
spaces  of  the  brain  is  also  drained  off  (Fig.  10). 
Hence  the  practice  of  lumbar  puncture  in  cases  of 
intracranial  pressure.  In  meningitis  the  cerebro- 
spinal  fluid  becomes  turgid ;  the  subarachnoid 
space,  or  parts  of  it,  may  contain  pus.  In  the 
spinal  column  the  arachnoid  is  widely  separated 
from  the  pia  mater,  consequently  the  subarachnoid 
space  is  extensive.  As  the  space  passes  into  the 
skull  it  forms  an  expansion  between  the  cerebellum 
and  the  roof  of  the  fourth  ventricle  named  the 
cisterna  magna  (Fig.  10) ;  an  opening  in  the  roof 
of  the  fourth  ventricle  (the  foramen  of  Ma^endie) 
allows  the  cerebro-spinal  fluid  in  the  ventricles  of 
the  brain  to  join  that  in  the  cisterna  magna  (Fig. 
10).  On  the  base  of  the  skull,  in  front  of  the  medulla 
and  pons,  the  spinal  subarachnoid  space  expands 
into  the  cisterna  pontiff,  which  in  turn  becomes 
continuous  with  a  large  space  situated  on  the  base 
of  the  brain  between  the  temporal  lobes  and  under 
the  interpeduncular  space — the  cisterna  basalis 
(Fig.  10).  In  this  cistern  are  situated  the  circle 
of  Willis,  the  third,  fourth,  and  root  of  the  fifth 
nerves,  the  optic  chiasma  and  tracts  and  infundi- 
bulum  of  the  pituitary  body.  In  basal  meningitis 
it  may  become  distended  with  pus.  The  inflam- 
matory adhesions  which  occur  in  the  inferior 
medullary  velum  may  lead  to  a  condition  of 
hydrocephaly  by  closing  up  the  openings  in  that 
membrane. 

Over  the  convolutions  of  the  brain  the  arach- 
noid is  bound  by  the  pia  mater,  which  here 


in]  SUBARACHNOID   SPACE  39 

serves  as  a  loose  subarachnoid  tissue.  Every- 
where extensions  of  the  basilar  cistern  pass  with 
the  arteries  derived  from  the  circle  of  Willis  into 
the  pia  mater  in  the  stilci  of  the  brain.  While 
the  interpeduncular  part  of  the  base  of  the  brain, 
pons  and  medulla  rest  on  these  basal  cisterns,  the 
temporal  and  frontal  lobes  lie  directly  on  the  base 
of  the  skull ;  the  occipital  lobe  rests  on  the  ten- 
torium  cerebelli.  The  three  poles  of  the  brain — 


UT  EDCEOFARACH10ID 

SUPRA-CALLOSM.  SPACE 


ClSTB 


Fig.   10.  -Diagram  of  the  cranial  spaces  containing 
cerebro-spinal  fluid. 

the  frontal,  occipital,  and  temporal — are  in  direct 
contact  with  the  meninges  and  skull,  and  are 
therefore  the  parts  of  the  brain  that  are  most 
liable  to  laceration  in  cases  of  injury  to  the  head. 
The  cerebro-spinal  fluid  prevents  the  ill  effects 
that  irregularities  in  the  blood  circulation  might 
have  upon  the  brain,  situate  as  it  is  within  an  un- 
yielding cavity.  If  the  great  nerve-centres  near 
the  lateral  ventricles  are  swollen  by  congestion, 
they  are  not  met  by  an  unyielding  wall,  but  merely 
displace  some  of  the  cerebro-spinal  fluid  through 


40  THE    HEAD    AND    NECK  [CHAP. 

the  foramen  of  Magendie,  until  such  time  as  their 
circulation  is  normal  again.  When  the  healthy 
brain  is  exposed  by  a  trephine  opening,  it  is  seen 
to  pulsate  with^each  beat  of  the  heart;  if  it  does 
not  pulsate,  this  shows  that  the  pressure  within 
the  skull  is  higher  than  the  arterial  pressure 
(100-130  mm.  Hg) ;  normally,  as  Hill  has  shown, 
the  intracranial  pressure  is  that  of  the  blood- 
pressure  in  the  veins  (10-15  mm.  Hg).  With  each 
pulsation  of  the  heart  about  5  c.c.  of  arterial  blood 
is  thrown  into  the  skull,  causing  the  ejection  of  a 
similar  amount  of  venous  blood  by  the  jugular 
vein. 

Fluid  may  pass  from  the  lateral  to  the  third 
ventricle  by  the  foramen  of  Monro ;  from  the  third 
to  the  fourth  ventricle  by  the  aqueduct  of  Sylvius ; 
and  from  the  fourth  ventricle  to  the  cisterna 
magna  by  the  foramen  of  Magendie  (Fig.  10).  Many 
still  share  the  opinion  of  Hilton  that  blockage 
of  the  aqueduct,  or  closure  of  the  foramen  of 
Magendie,  or  of  the  other  two  openings  at  the 
lateral  angles  of  the  fourth  ventricle  (the  fora- 
mina of  Key  and  Retzius)  may  prevent  the  exit  of 
cerebro-spinal  fluid  from  the  ventricles  and  thus 
produce^the  condition  of  hydrocephaly.  The  fluid 
also  drains  into  the  veins  of  Galen,  hence  pressure 
on  these  may  bring  about  a  like  result.  It  has  been 
proposed  to  relieve  the  pressure  within  the  lateral 
ventricles  in  cases  of  hydrocephalv  by  draining  the 
cerebro-spinal  fluid  ( into  the  subdural  space  by 
means  of  a  seton.  It  is  absorbed  under  any  pressure 
above  that  within  the  cerebral  veins  (Hill).  If  the 
brain,  too,  becomes  enlarged  by  congestion,  it  is 
not  met  by  unyielding  bone,  but  rather  by  an  ad- 
justable water-bed,  and  during  its  period  of  en- 
largement it  merely  displaces  into  the  spinal  part 
of  the  subarachnoid  space  some  of  the  fluid  that 
surrounds  it.  This  mutual  effect  is  well  illustrated 
in  a  case  reported  by  Hilton  of  a  man  with  a  frac- 
ture of  the  base,  from  whose  ear  cerebro-spinal 
fluid  was  escaping.  The  discharge  of  this  fluid 
was  at  once  greatly  increased  by  expiratory  efforts 


ML]  ('KKKBKO  SI'IXAL   FLUID  tl 

when  the  nose  and  mouth  were  held  closed  and  UK- 
veins  compressed  in  the  neck. 

Cerebro-spiiial  fluid.— Tho  total  amount  of 
fluid  in  the  cerebro-spinal  system  of  an  adult  is 
estimated  at  130-150  c.c.  (about  4^  oz.).  It  is 
secreted  by  the  choroid  plexuses  (1)  in  the  lateral 
ventricles,  (2)  in  the  roof  of  the  third  ventricle, 
and  (3)  in  the  roof  of  the  fourth  ventricle,  the 
ependymal  epithelium  covering  these  plexuses 
being  regarded  as  the  actual  structure  carrying 
out  the  secretion.  The  fluid  is  absorbed  (1)  by 
the  lymphatic  spaces  surrounding  the  nerve  roots, 

(2)  by  passage  into  veins  and  venous  spaces,  and 

(3)  the  Pacchionian  bodies  also  serve  as  a  means 
whereby  it  enters  the  venous  system.     Methylene 
blue,  when  injected  into  the  spinal  subarachnoid 
space,   quickly   appears   in   the   ventricles   of   the 
brain,    from    which    we   see   that   diffusion    takes 
place    rapidly.      It"  also    appears    almost    imme- 
diately  in   the   circulation,    being   eliminated   by. 
the  kidneys.      It  is   absorbed   much   more   slowly 
by  lymphatics,  for  the  glands  of  the  neck  do  not 
become  stained  until  some  time  has  elapsed. 

Pituitary  body.— In  recent  years  the  pitui- 
tary body,  enclosed  within  a  special  compartment 
of  the  dura  mater,  and  placed  on  the  upper 
surface  of  the  basi-sphenoid,  has  assumed  an 
increased  surgical  importance.  In  Fig.  11  its 
form  and  relationships  are  shown  as  seen  in  a 
young  child.  Its  stalk  descends  from  the  floor 
of  the  third  ventricle,  and  ends  in  the  posterior 
or  neural  lobe.  The  anterior  or  glandular^  lobe 
is  applied  to  the  neural  lobe  and  embraces  it  on 
each  side.  The  glandular  lobe,  which  arises  as 
an  outgrowth  from  the  stomodseum  or  mouth- 
depression  of  the  embryo,  is  divided  into  two 
parts — a  perineural-  or  intermediate  part  (Her- 
ring), which  is  closely  applied  to  the  neural 
lobe,  and  an  anterior  or  preneural  part.  The 
nerineural  and  preneural  parts  are  separated 
by  a  central  cavity,  which  is  obliterated  as 
adult  life  is  reached  (Fig.  11).  The  preneural 


THE    HEAD    AND    NECK 


[CHAP. 


glandular  part  may  become  hypertrophied  and 
form  a  glandular  tumour,  and  in  many  of  these 
cases  various  parts  of  the  body— especially  the 
face,  hands  and  feet— -begin  to  grow,  and  attain 
a  large  size,  giving  rise  to  the  condition  known 
as  acromeyaly.  If  the  hypertrophy  occurs  in 
youth,  then  all  the  bones  of  the  skeleton  grow 
rapidly,  and  the  condition  of  giantism  is  pro- 


ARACH. 

DURA  MATER 
INFUNDIBULUM 
PRESPHEN. 
PERINEURAL  LOBE 
PRENEURAL   LOBE 
TRACK  OF  DEVELOPMENT 


NASI 
Q.  PITUITARY 


PHARYNQ. 
TONSIL 


SOFT  PALATE 


Fig.  11. — Section  of  the  pituitary  body,  third  ventricle, 
basi-sphenoid,  and  naso-pharynx  of  a  child  aged  15 
months.  The  emnant  of  the  stalk  of  the  pituitary  out- 
growth is  represented  in  the  roof  of  the  naso-pharynx. 

duced.  The  preneural  glandular  part  of  the 
pituitary — evidently  by  means  of  an  internal  se- 
cretion— regulates  the  growth  of  the  various  parts 
of  the  body,  and,  if  secretion  is  in  excess,  leads 
to  overgrowth.  Numerous  cases  have  been  relieved 
by  operation,  part  of  the  glandular  lobe  being 
scraped  away.  In  the  adult,  access  to  the  pituitary 
is  obtained  through  the  sphenoidal  sinus,  on  the 
roof  of  which  this  body  is  situated.  The  sinus 


in]  PITUITARY   BODY  43 

is  reached  by  reflecting  the  cartilaginous  part 
of  the  nose  and  following  the  septum  nasi 
backwards  until  the  sphenoidal  sinus  is  reached. 
Another,  and  perhaps  better,  route  is  by  the 
temporal  fossa.  In  order  that  the  temporal 
lobe  of  the  brain  may  be  lifted  up  to  expose 
the  pituitary  body,  it  is  necessary  to  trephine 
extensively  the  opposite  temporal  fossa.  Pituitary 
tumours,  as  they  expand,  compress  the  cavernous 
sinuses,  and,  from  their  close  relationship  to  the 
optic  nerves,  lead  usually  to  a  partial  optic 
atrophy  and  blindness.  ^  The  tumour  may  depress 
the  roof  of  the  sphenoidal  sinus.  In  Fig.  11  a 
remnant  of  the  stalk  of  the  developing  pituitary  is 
shown  in  the  roof  of  the  naso-pharynx.  Erdheim 
found  that  this  remnant  of  the  fretal  pituitary 
(the  naso-pharyngeal  pituitary)  occurred  in  every 
one  of  the  bodies  that  he  examined— over  fifty 
in  number.  The  blood  supply  of  the  pituitary  is 
from  numerous  vessels  which  arise  from  the  circle 
of  Willis  and  descend  in  the  stalk  of  the  pituitary. 
The  pituitary  is  contained  within  a  compartment 
of  the  dura  mater,  the  roof  of  which  is  perforated 
by  the  stalk  of  the  body.  (The  X-ray  position  and 
appearance  of  the  pituitary  fossa  is  shown  in 
Fig.  9,  p.  32). 

Surface  relationships  of  the  brain  (see 
Figs.  12  and  13). — The  longitudinal  fissure  of  the 
brain  is  indicated  by  a  line  drawn  along  the  vertex 
from  the  glabella  to  the  external  occipital  protu- 
berance. It  is  narrow  in  front,  but  as  it  contains 
the  longitudinal  sinus,  which  rapidly  enlarges  as 
it  passes  backwards,  it  becomes  of  considerable 
breadth  behind,  and  as  a  rule  lies  somewhat 
towards  the  right  of  the  median  line,  owing  to  the 
predominance  of  the  left  cerebral  hemisphere. 
Between  the  external  occipital  protuberance  and 
the  ear,  the  lateral  sinus  bounds  the  lower  level 
of  the  cerebrum  and  the  upper  of  the  cerebellum 
(Figs.  4  and  12).  In  front  of  the  ear  the  upper 
border  of  the  zygoma  in  its  posterior  three-fourths 
mlarks  the  lower  border  of  the  temporal  lobe.  The 


44 


THE    HEAD    AND    NECK 


[CHAP. 


pole  of  the  temporal  lobe  is  f  of  an  inch  behind  the 
outer  margin  of  the  orbit  (sec  Fig.  4).  The  lower 
limit  of  the  brain  on  the  forehead  may  be  indicated 
approximately  by  drawing  a  line  from  the  glabella 
to  the  Sylvian  point,  i  an  inch  above  the  upper 


FISSUREor  ROLANDO 


PARIETAL 
EMINENCE 


PARIETO 
OCCIPIT 
FI55U 


BREQMA 


NASION 


INION.. 


Fig.  12. — Showing  the  relation  of  the  brain  and  sensori- 
motor  areas  of  the  cortex  to  the  skull      (Mod'tfcd  from 

0,'iain.) 

The  sensori -motor  areas  are  shaded — the  leg  and  trunk  areas  with 
vertical  lines ;  the  arm  and  hand  areas  with  lines  slanting  for- 
wards ;  the  face  and  mouth  areas  with  lines  slanting  back- 
wards ;  the  tongue,  pharynx,  and  larynx  areas  are  stippled.  The 
ascending  frontal  convolution,  containing  the  areas  which  are 
strictly  motor  in  function,  is  indicated  by  red  lines.  The  motor 
centre  for  speech  on  Broca's  convolution  is  shaded  with  horizontal 
lines.  The  "  word-hearing  "  centre  is  indicated  on  the  superior 
temporal  convolution,  and  the  "  word-seeing "  centre  on  the 
angular  convolution.  The  area  shaded  with  horizontal  lines  on 
the  posterior  parts  of  the  middle  and  inferior  frontal  convolutions 
is  the  centre  for  combined  movements  of  the  head  and  eyes. 


mj  FISSURE   OF   ROLANDO  45 

margin  of  the  orbit.  The  olfactory  bulbs  lie  at 
the  level  of  the  nasion  (Fig.  4). 

The  cerebellum  is  best  explored  at  a  point  1^ 
inches  behind  and  |  an  inch  below  the  level  of 
the  external  auditory  meatus  (see  Fig.  4).  It 
is  deeply  placed,  being  covered  by  the  insertions 
of  the  occipital  muscles. 

Of  the  many  methods  which  have  been  sug- 
gested for  marking  out  the  fissure  of  Rolando, 
the  most  simple  and  accurate  is  the  following  :  A 
point  over  the  sagittal  suture  is  taken  midway 
between  the  glabella  and  external  occipital  pro- 
tuberance. Half  an  inch  behind  this  mid-point 
the  upper  end  of  the  fissure  terminates  (Fig.  13). 
A  line  3|  inches  long  drawn  downwards  and 
forwards  from  this  point,  at  an  angle  of  67°  to 
the  line  of  the  sagittal  suture,  will  indicate  the 
position  of  the  fissure  of  Rolando  in  the  adult. 
In  the  child  the  fissure  is  shorter  and  the  con- 
tained angle  is  5°  smaller.  The  angle  is  easily 
obtained  by  folding  twice  the  corner  of  a  square 
piece  of  paper  and  removing  a  fourth  of  the 
right  angle.  This  line  may  not  lie  exactly  over 
the  fissure,  for  it  varies  somewhat  in  position 
according  to  the  shape  of  head.  The  sensori- 
motor  areas  of  the  brain  are  mostly  represented 
in  the  ascending  frontal  and  parietal  convolu- 
tions which  bound  the  fissure  of  Rolando.  The 
average  width  of  each  of  these  convolutions  is 
I  of  an  inch.  The  coronal  suture  is  about  2  inches 
in  front  of  the  fissure  of  Rolando  at  its  upper 
part  and  1^  inches  at  its  lower. 

The  fissure  of  Sylvius  is  indicated  thus 
(Fig.  13) :  A  point  is  taken  1^  inches  behind 
and  -|  an  inch  above  the  fronto-malar  junction, 
which  is  marked  by  a  distinct  notch.  This  point 
on  the  temple  overlies  the  anterior  inferior  angle 
of  the  parietal  bone — the  pterion.  The  pterion 
marks  the  junction  of  the  three  limbs  of  the 
fissure  of  Sylvius  with  its  stem.  A  line  drawn 
backwards  and  upwards  from  the  pterion  to  a 
point  |  of  an  inch  below  the  parietal  eminence 


46 


THE    HEAD    AND    NECK 


[CHAP. 


indicates  the  situation  of  the  posterior  horizontal 
limb  or  ramus  (Fig.  13).  If  the  parietal  eminence 
be  not  well  marked,  then  the  fissure  may  be  in- 
dicated by  joining  the  fronto-malar  notch  with 
the  pterion  and  prolonging  the  line  thus  formed 


Fig.   13.— Showing  the  lines  which  indicate  the  position  of 
the  principal  fissures  of  the  brain. 

Reid's  base  line  is  drawn  from  the  lower  margin  of  the  orbit  back- 
wards through  the  meatal  point. 

straight  backwards  to  the  region  of  the  parietal 
eminence,  as  shown  in  Fig.  4  (R.  J.  Berry).  This 
ramus  is  bounded  below  by  the  superior  temporal 
convolution,  which  contains  in  its  middle  third 
the  "word-hearing "  centre  (Fig.  12).  Above,  it 


in]  FISSURE   OF  SYLVIUS  47 

is  bounded  from  before  backwards  by  the  basilar 
part  of  the  inferior  frontal  convolution,  the  lower 
ends  of  the  ascending  frontal  and  parietal  con- 
volutions, and  the  supramarginal  gyrus.  In  the 
three  parts  first  named  are  situated  centres  for 
movements  of  the  tongue,  larynx,  pharynx,  and 
mouth.  A  penny  piece  placed  directly  behind  the 
termination  of  the  Sylvian  line  will  cover  the 
angular  convolution  in  which  the  "  word-seeing  ;; 
centre  is  placed  (Fig.  12).  The  parietal  eminence 
covers  the  supramarginal  convolution.  The  ascend- 
ing limb  of  the  fissure  of  Sylvius  is  indicated 
by  a  line  \  of  an  inch  long  drawn  upwards  and 
slightly  forwards  from  the  pterion,  while  the  short 
anterior  horizontal  limb  is  indicated  by  a  line 
\  an  inch  long  drawn  forwards  from  the  same 
point.  Between  the  ascending  and  anterior  limbs 
is  situated  the  pars  triangularis  of  the  inferior 
frontal  convolution  in  which  the  centre  for 
"  motor  speech  "  is  placed.  Broca  regarded  the 
left  inferior  frontal  convolution  (frequently 
called  Broca's  convolution)  as  specially  connected 
with  speech,  but  more  recently  Pierre  Marie  and 
others  have  published  accounts  of  a  number  o"f 
cases  of  disease  of  this  part  in  which  speech 
was  unaffected.  The  stem  of  the  Sylvian  fissure  is 
i  an  inch  long  and  runs  downwards  and  forwards 
under  the  great  wing  of  the  sphenoid  (Fig.  12). 
The  temporal  pole  lies  below  it. 

The  four  angles  of  the  parietal  bone  have 
important  relationships  to  the  brain.  The  anterior 
inferior  angle  covers  the  posterior  part  of  the 
inferior  frontal  convolution  and  the  anterior 
horizontal  and  ascending  limbs  of  the  fissure 
of  Sylvius.  The  anterior  branch  of  the  middle 
meningeal  artery  with  its  accompanying  sinus 
ascends  beneath  it.  The  anterior  superior  angle 
at  the  bregma  covers  the  terminal  part  of  the 
superior  frontal  convolution  and  the  centre  for 
movements  of  the  hip.  The  posterior  superior 
angle  at  the  lambda  lies  over  the  upper  part 
of  the  occipital  lobe  and  %  an  inch  behind  the 


48  THE    HEAD    AND   NECK  [CHAP. 

parieto-occipital  fissure.  The  posterior  ^inferior 
angle  covers  the  convexity  of  the  lateral  sinus  and 
marks  the  lower  limit  of  the  cerebrum.  In  its 
anterior  half  the  posterior  limb  of  the  Sylvian 
fissure  lies  beneath  the  squamous  suture,  but  be- 
hind it  passes  entirely  beneath  the  parietal  bone. 
It  will  be  thus  seen  that  the  parietal  bone  covers 
the  whole  of  the  parietal  lobe,  the  posterior  parts 
of  the  frontal  and  temporal  lobes,  and  the  upper 
margin  of  the  occipital. 

The  inferior  temporal  convolution  passes 
backwards  above  the  upper  border  of  the  zygoma 
and  external  auditory  meatus  and  rests  on  the 
thin  roof  of  the  tympanum.  Hence  it  is  the  most 
common  site  of  abscess  which  may  follow  middle- 
ear  disease.  (Fig.  12.) 

The  basal  ganglia  of  the  brain — the  corpus 
striatum  and  optic  thalamus — are  capped  on  their 
outer  aspect  by  the  island  of  Reil.  The  island 
lies  buried  in  the  anterior  three-fourths  of  the 
fissure  of  Sylvius,  and  hence  the  surface  markings 
for  the  fissure  may  be  also  used  for  the  island 
and  the  basal  ganglia  (see  Fig.  4,  p.  15).  A 
half-circle,  with  a  radius  of  half  an  inch,  drawn 
in  front  of  the  pterion,  will  indicate  the  anterior 
limit  of  the  basal  ganglia,  while  their  posterior 
limit  lies  some  distance  ^  in  front  of  the  point  at 
which  the  lateral  ventricles  may  be  tapped  (see 
Fig.  3,  p.  13).  That  point  is  found  thus:  a 
line  5  cm.  (2  inches)  in  length  is  drawn  verti- 
cally upwards  from  the  external  auditory  meatus ; 
the  point  for  tapping  the  lateral  ventricle  lies 
2  cm.  (£  of  an  inch)  behind  the  upper  end  of 
this  line;  a  trocar  thrust  in  there  enters  the 
lateral  ventricle  at  the  junction  of  the  body  with 
the  descending  and  posterior  horns.  (Jenkins.) 

Sensori-motor  areas  of  the  brain.— A 
knowledge  of  the  position  of  these  areas  is  most 
important  in  enabling  certain  brain  lesions  to  be 
localized  and  in  guiding  the  surgeon  in  operations 
upon  the  cerebral  cortox. 

Formerly  theso  areas  \u-iv  believed   to  be  situ- 


Ill] 


SENSORI-MOTOR   AREAS 


49 


ated  in  the  ascending  frontal  (precentral)  and  also 
ascending  parietal  (postcentral)  convolution,  but 
by  stimulating  more  accurately  the  cortex  of  these 
convolutions  in  anthropoid  apes,  Sherririgton  and 
Grunbaum  found  that  motor  reactions  were 
elicited  only  from  the  ascending  frontal.  The 
arrangement  of  the  motor  areas  is  shown  in  Fig. 
14 :  in  the  upper  third  of  the  ascending  frontal, 


Fig.  14  —Showing  the  localization  of  motor  areas  in  the 
precentral  or  ascending  frontal  convolution,  and  the 
sensory  areas  in  the  postcentral  or  ascending  parietal 
convolution. 

passing  also  some  distance  on  to  the  mesial  aspect 
of  the  brain,  the  movements  of  the  lower  extremity 
and  trunk  are  represented;  in  the  middle  third, 
those  of  the  arm ;  while  in  the  lower  third,  those 
of  the  face,  mouth,  and  larynx.  Recently  Sym- 
ington and  Crymble  have  investigated  the  size 
and  shape  of  the  central  or  Rolandic  fissure,  and 
have  found,  as  shown  in  Fig.  15,  that  in  the 
majority  of  brains  this  fissure  is  pushed  back- 
wards at  two  points  by  an  upper  and  lower 
eonvolutionary  buttress.  The  position  of  these 


50 


THE    HEAD    AND    NECK 


[CHAP. 


buttresses,  their  relationship  to  motor  areas  and 
distance  from  the  sagittal  suture,  are  shown  in 
Fig.  15. 

Behind  the  fissure  of  Rolando,  in  the  ascend- 
ing parietal  convolution,  are  situated  sensory 
areas  corresponding  to  the  motor  areas  in  the 
ascending  frontal  convolution.  A  tumour  press- 

LONG1TUDINAL      F1S.> 


FISSURE    O 

Fig.     15. — The    convolutionary    projections    of    the    pre- 
central  gyms,  and    their   relationship  to  motor  areas. 

(Symington  and  Crymblc.) 

ing  on  the  surface  of  the  brain  first  excites 
the  cortex  to  action;  hence  one  situated  over  a 
motor  area  excites  the  movements  represented 
in  that  area,  or  one  over  a  sensory  area  excites 
the  sensations  represented  there.  Stimulation  of 
the  cortex  is  soon  followed  by  its  destruction 
and  loss  of  function;  hence  loss  of  movement 
or  loss  of  sensation  replaces  the  preliminary 


in]  THE   BRAIN  51 

excitement.  The  symptoms  produced  by  intra- 
cranial  growths  are  apt  not  to  be  definitely 
localized,  because  even  a  small  tumour  may  pro- 
duce widely  distributed  compression  effects  when 
it  is  situated  within  the  rigid  walls  of  the  skull. 
Conjugate  movements  of  the  eyes  are  represented 
in  the  cortex  at  the  posterior  end  of  the  mid- 
frontal  convolution  (Fig.  14).  There  are  also 
several  primary  sensory  areas  of  cortex — areas 
connected  with  sight,  hearing,  and  smell — which 
may  be  affected  by  intracranial  lesions,  and  give 
signs  which  assist  the  surgeon  ^  to  localize  the  seat 
of  disease.  The  visual  cortex  is  situated  near  the 
calcarine  fissure  and  round  the  occipital  pole; 
the  "word-seeing"  centre  occupies  the  angular 
gyrus  (Fig.  12) ;  the  auditory  cortex  lies  in  a  deep 
or  buried  part  of  the  superior  temporal  convolu- 
tion, while  the  "  word-hearing  "  centre  is  ascribed 
to  the  middle  third  of  this  convolution.  The  ol- 
factory cortex  is  placed  in  the  uncus,  which  is 
situated  to  the  inner  side  of  the  temporal  lobe. 
Tumours  in  the  neighbourhood  of  the  uncus,  besides 
producing  disturbance  of  the  olfactory  sensations, 
frequently  give  rise  to  "dreamy  states." 

Of  the  brain  generally  little  has  to  be  said. 
In  a  surgical  sense,  it  presents  itself  simply  as  a 
large  mass  of  soft  tissue  that  may  be  damaged  by 
shaking,  as  gelatin  may  be  when  shaken  in  a  case. 
As  it  is  of  very  yielding  structure,  and  does  not 
entirely  fill  the  cranial  cavity,  it  may,  as  it  were, 
be  thrown  about  within  the  skull,  and  be  damaged 
by  collision  with  its  walls.  In  contusion  or  bruis- 
ing of  the  brain  it  is  noticed  that  the  lesion  is 
very  much  more  frequently  situate  on  the  under 
surface,  both  as  regards  the  cerebrum  and  cere- 
bellum, than  in  any  other  part  (see  p.  39).  To 
this  statement,  however,  there  is  the  striking 
exception  that  those  parts  of  the  base  of  the 
cerebrum  that  rest  upon  the  large  basal  collection 
of  the  cerebro-spinal  fluid  are  the  least  often  con- 
tused. These  parts  include  the  medulla,  the  pons, 
an-d  the  interpeduncular  space. 


52  THE    HEAD    AND    NECK  (CHAP 

Blood  supply. — The  brain  is  very  lavishly  sup- 
plied with  blood-vessels.  The  main  arterial  trunks 
(vertebral  and  internal  carotid)  both  become  tortu- 
ous before  entering  the  skull,  in  order,  probably, 
to  diminish  the  effects  of  the  heart's  systole  upon 
the  brain.  On  entering  they  are  almost  immedi- 
ately blended  into  an  anastomosing  circle  (circle 
of  Willis),  which  has  the  effect  of  equalizing  the 
cerebral  circulation.  It  is  only  when  one  of 
the  main  arteries  entering  into  the  formation 
of  the  circle  of  Willis  becomes  blocked  that  the 
communicating  channels  are  of  service.  If  a 
coloured  solution  be  injected  into  the  left  carotid 
of  a  living  dog,  the  colouring  is  confined  to  the 
left  hemisphere ;  but  if  the  right  carotid  be  pre- 
viously tied,  then  the  colouring  matter  is  found 
in  the  right  as  well  as  the  left  half  of  the 
brain  (Kramer).  Embolism  of  the  middle  cere- 
bral artery  leads  to  a  widespread  destruction  of 
the  cerebral  cortex.  It  supplies  the  third  frontal, 
the  upper  and  middle  temporal,  the  angular, 
supramarginal,  and  the  lower  two- thirds  of  the 
ascending  frontal  and  parietal  gvri.  The  only 
parts  of  the  sensori-motor  areas  which  escape  de- 
struction in  such  a  case  are  those  for  the  lower 
limbs  and  trunk.  The  anterior  cerebral  artery 
supplies  these  centres,  the  mesial  surface  of  the 
frontal  and  parietal  lobes,  and  the  adjacent  part 
of  the  cortex  on  the  outer  aspect.  The  occipital 
lobe  and  temporo-sphenoidal  convolutions  are 
supplied  by  the  posterior  cerebral  artery.  Liga- 
ture of  one  common  carotid  may  produce  no  effect 
upon  the  brain,  although  the  mortality  after  this 
operation  is  mainly  due  to  cerebral  complica- 
tions. One  carotid  and  the  two  vertebrals  would 
appear  to  be  able  to  bring  enough  blood  to 
the  brain,  but  some  weeks  will  elapse  before  the 
communicating  vessels  are  sufficiently  enlarged 
to  give  a  uniform  distribution  of  blood  to  all 
parts  of  the  brain.  Both  common  carotids  have 
been  ligatured,  or  one  carotid  has  been  secured 
when  its  fellow  of  the  opposite  side  has  been 


in]  CEREBRAL   BLOOD   SUPPLY  53 

occluded  by  disease,  and  no  marked  cerebral 
disturbances  have  followed.  In  no  case,  how 
ever,  has  the  patient  recovered  when  the  interval 
between  the  closing  of  the  two  vessels  was  less 
than  a  few  weeks.  The  vertebral  arteries  can 
carry  a  sufficient  amount  of  blood  to  the  brain 
if  only  the  strain  be  thrown  upon  them  gradu- 
ally, and  the  brain  be  allowed  to  accommodate 
itself  slowly  to  the  change.  After  ligaturing  all 
four  arteries  in  the  dog,  the  anastomosis  between 
the  spinal  and  cerebral  arteries  within  the  fora- 
men magnum  was  sufficient  to  maintain  life 
(Hill).  Plugging  of  any  of  the  smaller  cerebral 
arteries  by  emboli,  as  a  rule,  leads  at  once 
to  a  disastrous  result.  Such  embolism  is  met 
with  in  surgery  in  connexion  with  aneurysm  of 
the  common  carotid.  In  simply  examining  such 
aneurysms,  a  little  piece  of  the  clot  contained  in 
the  sac  has  been  detached,  has  been  carried  up 
into  the  brain,  and  has  produced  a  plugging  of 
one  of  the  cerebral  vessels.  Thus,  hemiplegia  has 
followed  upon  the  mere  examination  of  a  carotid 
aneurysm,  as  in  a  case  recorded  by  Mr.  Teale,  of 
Leeds.  Fergusson's  treatment  of  aneurysm  at  the 
root  of  the  neck,  that  of  displacing  the  clots  by 
manipulation,  has  been  abandoned  on  this  same 
score.  In  the  second  case  treated  by  manipula- 
tion by  this  surgeon,  one  of  subclavian  aneurysm, 
paralysis  of  the  left  side  of  the  body  followed  at 
once  upon  the  first  handling  of  the  tumour. 

The  pulsations  of  the  brain  may  be  communi- 
cated to  any  tumours  or  collections  of  fluid  that 
reach  the  surface  of  the  brain  through  an  aper- 
ture in  the  skull.  Such  pulsations  are  synchron- 
ous with  the  arterial  pulse,  but  the  sphygmo- 
graphic  tracings  of  the  cerebral  pulsations  exhibit 
also  the  "respiratory  curve,"  conveyed  directly 
from  the  thorax  by  the  blood  within  the  veins. 
The  valve  at  the  lower  end  of  the  jugular  vein 
prevents  direct  regurgitation  of  blood  from  the 
heart  to  the  brain,  but  it  does  not  prevent  the 
transmission  of  pressure. 


54  THE    HEAD    AND    NECK 

Although  wounds  of  the  brain  bleed  freely, 
the  bleeding  is  checked  without  difficulty,  the 
vessels  being  capable  of  ready  contraction.  Large 
tumours  have  been  excised  from  the  cortex  of 
the  brain,  without  undue  trouble  from  haemor- 
rhage. The  terminal  branches  of  the  cerebral 
arteries  anastomose  freely  in  the  pia  mater,  but 
the  minute  arteries  which  perforate  and  supply 
the  cortex  are  terminal.  Hence  any  pressure 
applied  to  the  surface  of  the  brain  will  lead 
to  anaemia  of  that  piece  of  cortex,  and,  if  the 
pressure  is  continued,  to  its  destruction. 

Ligature  of  a  cerebral  vein  usually  leads  to  an 
atrophy  of  the  cortex  which  it  drains  (Horsley). 
There  is  always  one — sometimes  more — anastomos- 
ing vein  on  the  surface  of  the  cerebrum,  uniting 
the  upper  with  the  lower  cerebral  veins.  The 
lower  cerebral  veins  are  four  in  number  :  three  of 
them  leave  the  temporal  and  occipital  lobes  to  end 
in  the  lateral  sinus;  the  other,  the  superficial 
Sylvian  vein,  ends  in  the  sinus  of  the  small  wing 
of  the  sphenoid.  The  temporal  and  occipital  lobes 
cannot  be  lifted  off  the  tentorium  without  rup- 
turing the  veins  joining  the  lateral  sinus. 

Nearly  all  the  veins  of  the  cerebellum  end 
in  the  lateral  sinus;  its  arteries  are  derived  from 
the  vertebral  and  basilar.  The  various  arteries 
supplying  the  cerebellum,  pons,  and  medulla  are 
terminal  in  their  ^  distribution,  each  nerve-centre 
and  area  having  its  own  vascular  supply  (Stop- 
ford).  Tumours  in  the  cerebellum  give  rise  to 
muscular  weakness  and  inco-ordination,  giddi- 
ness, and  loss  of  balance.  The  vermis,  or  middle 
part  of  the  cerebellum,  is  more  directly  connected 
with  bending  movements  of  the  trunk,  while  the 
lateral  lobes  are  concerned  in  the  co-ordination 
of  turning  movements— movements  made  round 
the  vertical  axis  of  the  trunk  (Horsley).  The 
evidence  is  steadily  increasing  which  makes  us 
regard  the  cortex  of  the  cerebellum  as  demar- 
cated into  functional  and  regional  areas. 


CHAPTER   IV 
THE    ORBIT    AND    EYE 

THE  ORBIT 

THE  antero-posterior  diameter  of  ^the  orbit  is 
about  If  inches  (44  mm.),  its  vertical  diameter 
at  the  base  a  little  over  1|  inches  (31  mm.), 
and  its  horizontal  diameter  at  the  base  about 
H  inches  (37  mm.).  The  diameters  of  the 
globe  are :  transverse,  24  mm. ;  antero-posterior, 
24-5  mm. ;  vertical,  23  mm.  (Brailey).  The  eye- 
ball is  therefore  nearer  to  the  upper  and 
lower  margins  of  the  orbit  than  to  the  sides, 
and  the  greatest  interval  between  the  globe 
and  the  orbital  wall  is  on  the  outer  side. 
The  interior  of  the  orbit  is  most  conveniently 
reached  by  incisions  made  to  the  outer  side 
of  the  globe,  and,  in  excision  of  the  eyeball, 
the  scissors  are  usually  introduced  on  that  side 
when  the  optic  nerve  has  to  be  divided.  In  excis- 
ing the  left  eye,  however,  it  may  be  more  con- 
venient to  divide  the  optic  nerve  from  the  inner 
side.  The  bones  forming  the  floor,  the  roof,  and 
the  inner  wall  of  the  orbital  cavity  are  very  thin, 
especially  in  the  last-named  situation.  Thus, 
foreign  bodies  thrust  into  the  orbit  have  readily 
penetrated  into  the  cranial  cavity,  into  the  nose 
and  ethmoidal  cells,  and,  when  directed  from 
above,  into  the  antrum  (see  Fig.  26,  p.  107).  In 
several  instances  a  sharp-pointed  instrument,  such 
as  the  end  of  a  stick  or  foil,  has  been  thrust 
into  the  brain  through  the  orbit,  and  has  left 
but  little  external  evidence  of  this  serious  lesion. 
55 


56  THE    HEAD    AND    NECK  [OWAI>. 

Nelatori  mentions  a  case  in   which  the  internal 
carotid  artery  was  wounded  through  the  orbit. 
A  reference  to  the  relations    of    the    orbital 

walls  will  show  that  a  tumour  may  readily  invade 
the  orbit  by  spreading  (1)  from  the  base  of  the  skull, 
(2)  from  the  nasal  fossae,  (3)  from  the  maxillary 
sinus,  and  (4)  from  the  temporal  or  infratemporal 
(zygomatic)  fossae.  In  any  of  these  instances  the 
growth  may  enter  the  orbit  by  destroying  the 
intervening  thin  layers  of  bone,  and  in  tumours 
of  the  maxillary  sinus  this  is  the  usual  mode 
of  entry.  It  may,  however,  extend  more  readily 
from  the  cranial  cavity  through  the  optic  foramen 
or  superior  orbital  (sphenoidal)  fissure,  from  the 
nose  through  the  naso-lacrimal  duct,  and  from 
the  two  fossae  named  through  the  inferior  orbital 
(spheno-maxillary)  fissure.  After  violent  blows 
upon  the  temple, .  blood  has  found  its  way  into 
the  orbit  through  the  inferior  orbital  fissure, 
and  has  led  to  subconj  unctival  ecchymosis.  Dis- 
tension of  the  frontal  sinus  by  retained  mucus 
or  pus  may  lead  to  a  prominent  tumour  at  the 
upper  and  inner  margin  of  the  orbit,  above  the 
level  .of  the  internal  (medial)  palpebral  ligament, 
which  may  cause  displacement  of  the  globe  down- 
wards, outwards,  and  forwards.  The  bones  of  the 
orbit  are  peculiarly  apt  to  be  the  seat  of  ivory 
exostoses,  which  may  in  time  entirely  occupy  the 
orbital  cavity. 

The  anterior  third  of  the  outer  wall  of  the 
orbit  is  separated  from  the  temporal  fossa  by  the 
malar  (os  zygomaticum)  (Fig.  16) ;  the  posterior 
two-thirds  are  separated  by  the  great  wing  of 
the  sphenoid  from  the  middle  fossa  of  the  skull, 
which  contains  the  temporal  lobe.  Kronlein  re- 
moves intraorbital  tumours  by  opening  the  outer 
wall  of  the  orbit  in  the  temporal  fossa.  In  a 
notorious  case,  in  which  a  murderer  attempted  to 
commit  suicide,  the  bullet  entered  the  temporal 
fossa,  perforated  the  outer  wall  of  the  orbit,  and 
destroyed  the  eyeball,  but  left  the  brain  un- 
touched. The  pole  of  the  temporal  lobe  is  situ- 


IVJ 


CAPSULE   OF  TENON 


57 


ated  from  2  to  2'5  cm.   behind  the  outer  margin 
of  the  orbit  (see  Fig.  4,  p.  15,  and  Fig.  9,  p.  32). 

Fascia  bulbi  (capsule  of  Tenon).— The  best 
description  of  this  structure  has  been  given  by 
Lockwood,  of  whose  researches  Prof.  Cunningham 
provides  the  following  resume:  — 

"  The  capsule  is  a  firm  loose  membrane  spread  over  the 
posterior  five-sixths  of  the  globe,  the  cornea  alone  being  free 


UT.TARSAL  Liq. 


CAPSULE 
TEMPORAL  FOSSA 

EXT.  CECTUS 


Fig.  16.— Showing  the  arrangement  of  the  capsule  of  Tenon 
(fascia  bulbi)  and  check  ligaments. 

The  eyeball  is  turned  outwards  so  that  the  external  check  ligament 
is  taut  and  the  internal  relaxed. 

from  it.  In  front  it  lies  under  the  ocular  conjunctiva,  with 
which  it  is  intimately  connected,  and  it  ends  by  blending  with, 
that  membrane  close  to  the  margin  of  the  cornea  [Fig.  16]. 
Behind,  it  fuses  with  the  sheath  of  the  optic  nerve,  where  the 
latter  pierces  the  sclerotic.  The  surface  of  the  membrane 
towards  the  globe  is  smooth,  and  is  connected  to  the  eyeball 
by  some  soft  yielding  areolar  tissue.  It  thus  forms  a  kind  of 
dome  for  the  globe,  a  species  of  socket  or  bursa  in  which  it 


58  THE    HEAD    AND    NECK  [CHAP. 

moves.  The  posterior  surface  of  the  capsule  is  in  contact 
with  the  orbital  fat.  The  tendons  of  the  ocular  muscles 
pierce  thfe  capsule  opposite  the  equator  of  the  globe  [Fig.  16]. 
The  lips  of  the  openings  through  which  the  four  recti  pass 
are  prolonged  backwards  upon  the  muscles,  in  the  form  of 
sheaths,  very  much  as  the  internal  spermatic  fascia  is  pro- 
longed upon  the  cord  from  the  internal  abdominal  ring." 

Where  the  internal  and  external  recti  per- 
forate, strong  expansions  of  the  capsule  spread 
out  to  the  inner  and  outer  walls  of  ^the  orbit. 
Because  these  expansions  limit  the  action  of  the 
two  recti  they  are  known  as  the  check  ligaments 
(Fig.  16).  They  allow  a  side-to-side  movement 
of  the . cornea  to  the  extent  of  about  45°.  The 
external  check  ligament  is  the  stronger,  and  is 
attached  to  the  outer  wall  immediately  behind 
the  external  palpebral  raphe  (tarsal  ligament)  ; 
the  attachment  of  the  internal  ligament  is  close 
behind  the  lacrimal  sac.  A  prolongation  of  the 
capsule  passes  to  the  trochlea  round  the  tendon  of 
the  superior  oblique.  The  suspensory  ligament 
of  the  eyeball  stretches  across  the  orbit  like  a 
hammock,  supporting  the  eyeball.  It  is  really 
a  thickening  of  the  under  part  of  the  fascia 
bulbi,  its  attachment  to  the  orbital  walls  being 
made  by  means  of  the  internal  and  external  check 
ligaments.  When  the  upper  jaw  is  removed  the 
surgeon  should  take  care  to  preserve  the  attach- 
ments of  the  suspensory  ligament.  If  these  be 
destroyed  the  eyeball  will  sink  downwards. 

The  intimate  relation  of  the  fascia  bulbi 
to  the  eyeball,  conjunctiva,  orbital  muscles,  and 
orbital  walls  has  to  be  kept  in  mind  where  opera- 
tions are  undertaken  to  remedy  squint.  From 
Fig.  16  it  will  be  seen  that,  after  the  tendon  of 
a  rectus  muscle  is  cut  through  as  it  lies  within 
the  cansnle  of  Tenon,  the  mnscle  still  possesses, 
through  the  continuity  of  its  sheath  with  the  cap- 
sule, an  attachment  to  the  eyeball  and  conjunc- 
tiva as  well  as  to  the  orbital  wall  by  the  check 
ligament.  Hence,  when  the  tendon  of  a  muscle  is 
completely  cut  it  can  still  act  on  the  eyeball ;  its 


ivj          FOREIGN   BODIES   IN   THE   ORBIT          59 

complete  retraction  is  prevented  by  the  check 
ligament. 

The  orbit  behind  the  fascia  bulbi  is  occupied 
by  a  large  quantity  of  loose  fat,  in  addition  to 
the  ocular  muscles,  vessels,  and  nerves.  It  is  by 
the  absorption  of  this  fat  that  the  sunken  eye 
is  produced  in  cases  of  emaciation  and  prolonged 
illness.  This  tissue  affords  a  ready  means  for  the 
spread  of  orbital  abscess.  Such  an  abscess  may 
follow  injuries,  certain  ocular  inflammations, 
periostitis,  etc.,  or  may  spread  from  adjacent 
parts.  The  pus  may  occupy  the  entire  cavity,  dis- 
placing the  eyeball  forwards,  limiting  its  move- 
ments, and  causing,  by  interference  with  the  cir- 
culation, great  redness  of  the  conjunctiva  and 
swelling  of  the  lids. 

Foreign  bodies,  some  of  them  of  remarkable 
size  and  shape,  have  lodged  for  long  periods  of 
time  in  the  orbital  fat  without  causing  much 
trouble.  Thus,  Lawson  reports  a  case  where  a 
piece  of  an  iron  hat-peg,  3  inches  long,  was  em- 
bedded in  the  orbit  for  several  days  without  the 
patient  being  aware  of  it.  A  stranger  case,  in 
some  ways,  is  that  reported  by  Furneaux  Jordan  : 
"  A  man  who  was  employed  in  threshing  became 
the  subject  of  severe  ophthalmia.  At  the  expira- 
tion of  several  weeks,  the  patient,  whilst  pressing 
his  finger  on  the  lower  eyelid,  suddenly  ejected 
from  a  comfortable  bed  of  warm  pus  a  grain  of 
wheat,  which  had  shot  forth  a  vigorous  green 
sprout."  The  orbital  fat  affords  also  an  excellent 
nidus  for  growing  tumours.  Fractures  of  the 
inner  wall  of  the  orbit  involving  the  nasal  fossae 
or  sinuses  may  lead  to  extensive  emphysema  of 
the  orbital  cellular  tissue.  The  air  so  introduced 
may  cause  the  globe  to  protrude,  may  limit  its 
movements,  may  spread  to  the  lids,  and  will,  in 
any  case,  be  increased  in  amount  by  blowing  the 
nose,  etc. 

Orbital  muscles.  —  The  four  recti  muscles 
end  in  thin,  flat  membranous  tendons.  The  ten- 
don of  the  external  or  internal  rectus  muscle  is 


60  THE    HEAD    AND    NECK  [CHAP. 

frequently  divided  for  strabismus.  The  width  of 
the  tendons  varies  from  7  mm.  to  9  mm.  They 
are  inserted  into  the  sclerotic  near  the  cornea. 
The  internal  rectus  is  inserted  6'5  mm.  from  the 
corneal  margin,  the  external  6*8  mm.,  the  inferior 
7'2  mm.,  and  the  superior  8  mm.  (Merkel). 

While  the  internal  and  external  recti  are  pure 
internal  and  external  rotators  of  the  eyeball,  the 
superior  and  inferior  recti,  owing  to  the  line  in 
which  they  pull,  act  as  internal  as  well  as  up- 
ward and  downward  rotators.  Their  tendency  to 
act  as  internal  rotators  is  counterbalanced  by  the 
two  oblique  muscles,  which  serve  as  external  as 
well  as  upward  and  downward  rotators. 

INF.  OBLIQ.     R.  SUP. 


SUP.   OBLIQ.      SUP.  OBLIQ. 

Fig.  17. — Diagram  to  show  the  action  of  the  orbital 
muscles.  The  arrows  show  the  direction  of  the 
action  of  each  muscle. 

The  diagram  given  in  Fig.  17  will  help  to 
make  the  actions  of  the  orbital  muscles  clearer. 
Conjugate  horizontal  movements  to  the  right  or 
left  are  executed  by  the  internal  and  external 
rectus  muscles.  When  the  cornea  is  turned 
upwards  the  muscles  in  action  are  the  inferior 
oblique  and  superior  rectus,  the  first-named  tend- 
ing to  turn  the  cornea  towards  the  temporal  as- 
pect, the  second  towards  the  nasal  aspect.  The  two 
muscles  involved  in  turning  the  cornea  down- 
wards are  the  inferior  rectus  and  superior  oblique, 
the  first  deflecting  the  movements  towards  the 
nasal  side,  the  second  towards  the  malar  side. 
The  diagram  also  serves  to  show  the  muscles  of 


iv]        ORBITAL  ARTERIES   AND  NERVES         61 

the  right  and  left  sides,  which  are  co-ordinated 
in  conjugate  movements.  Thus,  in  turning  the 
eyes  downwards  and  to  the  right,  the  superior 
oblique  of  the  right  side  acts  with  the  inferior 
rectus  of  the  left.  If  one  of  these  muscles  is 
paralysed,  then  double-vision  or  diplopia  occurs 
when  this  movement  is  carried  out.  Further,  it 
must  be  remembered  that  in  all  of  these  move- 
ments the  muscle  which  is  positively  in  action 
is  controlled  by  its  opponent,  which  is  negatively 
in  action.  If  the  opponent  should  become  para- 
lysed, the  active  muscle  pulls  on  the  eyeball  until 
it  is  opposed  by  the  check  ligament.  In  life,  all 
the  orbital  muscles  are  in  a  state  of  tonus  and 
exert  a  pressure  on  the  eyeball. 

The  orbital  arteries  are  small,  and  seldom 
give  rise  to  trouble  when  divided  in  excising 
the  globe,  since  they  can  be  readily  compressed 
against  the  bony  walls  of  the  cavity.  Pulsating 
tumours  of  this  part  may  be  due  to  traumatic 
aneurysms  of  one  of  the  orbital  arteries,  or  may 
depend  upon  an  arterio-venous  aneurysm  formed 
between  the  internal  carotid  artery  and  the 
cavernous  sinus.  Pressure  upon  the  ophthalmic 
vein  (as  it  enters  the  sinus)  by  an  aneurysm  of 
the  internal  carotid  vessel  may  also  produce  ^  all 
the  symptoms  associated  with  pulsating  orbital 
tumours.  Thrombosis  of  the  cavernous  sinus 
causes  dilatation  of  the  ophthalmic  veins  and 
proptosis. 

The  orbital  nerves  may  be  damaged  in 
wounds  of  the  orbit,  or  in  fractures  of  the  orbit 
and  of  the  base  of  the  skull;  they  may  be  pressed 
upon  by  tumours  from  various  parts,  by  aneu- 
rysms, hsemorrhagic  and  inflammatory  effusions. 
Thus,  Lawson  records  a  case  in  which  the  optic 
nerve  was  divided  by  a  stab  through  the  upper 
eyelid,  without  the  globe  being  injured,  and  with- 
out any  bone  being  fractured.  The  same  nerve 
has  also  been  completely  torn  across  in  fractures 
of  the  orbit,  and  has  been  pressed  upon  in  frac- 
tures involving  the  lesser  wing  of  the  sphenoid. 


62  THE    HEAD    AND    NECK  [CHAP. 

The  third,  fourth,  and  sixth  nerves,  and  the  tirst 
division  of  the  fifth,  may  be  affected  in  cases  of 
aneurysm  involving  the  internal  carotid  artery, 
where  they  lie  in  relation  with  the  cavernous 
sinus.  They  may  readily  be  pressed  upon,  also,  by 
any  growth  involving  the  inferior  orbital  fissure, 
such  as  a  periosteal  node  springing  from  the  mar- 
gin of  the  fissure,  while  the  sixth  nerve,  from  its 
more  intimate  connexion  with  the  base  of  the 
skull,  has  been  directly  torn  across  in  a  fracture 
involving  that  part  (Prescott  Hewett). 

In  paralysis  of  the  third  nerve  there  is  droop- 
ing of  the  upper  lid  (ptosis) ;  the  eye  is  almost 
motionless,  presents  a  divergent  squint  from 
unopposed  action  of  the  external  rectus  muscle, 
and  cannot  be  moved  either  inwards,  upwards, 
or  directly  downwards.  Rotation,  in  a  direc- 
tion downwards  and  outwards,  can  still  be 
effected  by  the  superior  oblique  and  outer  rectus 
muscles.  The  pupil  is  dilated  and  fixed;  the 
power  of  accommodation  is  much  impaired,  there 
is  diplopia,  and  sometimes  a  little  protrusion  of 
the  globe  from  relaxation  of  the  recti  muscles. 
These  symptoms  refer  to  complete  paralysis  of  the 
nerve.  In  cases  of  partial  paralysis,  only  one  or 
two  of  the  above  symptoms  may  be  present. 

In  paralysis  of  the  fourth  nerve  there  is  often 
but  little  change  to  be  seen,  since  the  func- 
tion of  the  superior  oblique  muscle,  supplied  by 
this  nerve,  may,  in  part,  be  performed  vicari- 
ously. "  There  is  usually  only  very  slight  defect 
in  the  mobility  of  the  eye;  what  there  is  occurs 
chiefly^  in  the  inner  and  lower  angle  of  the  field 
of  vision ;  there  is  deviation  of  the  eye  inwards 
and  upwards  on  lowering  the  object,  and  simply 
upwards  when  it  is  turned  far  towards  the  healthy 
side  "  (Erb).  In  any  case  there  will  be  diplopia, 
especially  in  certain  positions  of  the  globe. 

In  paralysis  of  the  sixth  nerve  there  is  con- 
vergent strabismus,  with  consequent  diplopia, 
and  an  inability  to  rotate  the  eye  directly  out- 
wards. Paralysis  of  the  sixth  nerve  may  be 


iv]         PARALYSIS   OF   ORBITAL  NERVES          63 

accompanied  by  paralysis  of  the  nerve  to.  the 
internal  rectus  of  the  opposite  side,  giving  rise  to 
conjugate  deviation  of  the  eyes.  Such  a  condi- 
tion indicates  a  lesion  in  the  nucleus  of  the  sixth 
nerve,  for,  although  the  fibres  for  the  internal 
rectus  pass  out  with  the  third  nerve,  they  take 
their  origin  with  the  sixth. 

Sometimes  all  the  oculo-motor  nerves  of  the 
eye  are  paralysed,  and  in  such  cases  the  lesion 
is  probably  situated  either  at  their  nuclei  of 
origin  or  at  the  cavernous  sinus,  in  the  wall  of 
which  the  nerves  lie  close  together. 

In  paralysis  of  the  first  division  of  the  fifth 
there  is  a  loss  of  sensation  in  all  the  conjunctiva, 
except  such  as  covers  the  lower  lid  (supplied  by 
the  palpebral  branch  of  the  infraorbital  nerve), 
loss  of  sensation  in  the  globe,  and  in  skin  sup- 
plied by  the  supratrochlear  and  supraorbital 
nerves,  and  in  the  mucous  and  cutaneous  surfaces 
supplied  by  the  nasal  (naso-ciliary)  nerve.  The 
area  of  anaesthesia  is  much  less  than  the  ana- 
tomical distribution  of  the  nerve,  owing  to  the 
extent  to  which  cutaneous  nerves  overlap.  No 
reflex  movements  (winking)  follow  upon  irri- 
tation of  the  conjunctiva,  although  the  patient 
can  be  made  to  wink  on  exposing  the  eye  to 
a  strong  light,  the  optic  nerve  in  this  case 
transmitting  the  impression  to  the  nucleus  of 
the  facial  nerve.  Neither  can  sneezing  be  ex- 
cited by  irritating  the  mucous  membrane  in  the 
anterior  part  of  the  nose.  Destructive  ulceration 
of  the  cornea  may  follow  this  paralysis,  due 
partly  ^to  damage  to  the  trophic  branches  con- 
tained in  the  paralysed  nerve,  partly  to  the  anaes- 
thesia which  renders  the  part  readily  injured,  and 
partly  to  the  loss  of  the  reflex  effect  of  the  sensory 
nerves,  upon  the  calibre  of  the  blood-vessels, 
wherebv  the  inflammation  is  permitted  to  go  un- 
controlled (Nettleship). 

In  paralysis  of  the  cervical  sympathetic  there 
is  narrowing  of  the  palpebral  fissure  from  some 
drooping  of  the  upper  lid,  apparent  recession 


64  THE    HEAD    AND    NECK  [CHAP 

of  the  globe  within  the  orbit,  and  some  narrow- 
ing of  the  pupil  from  paralysis  of  the  dilator 
muscle  of  the  iris,  which  muscle  is  supplied  by  the 
sympathetic.  The  drooping  of  the  upper  lid  may 
be  explained  by  the  fact  that  each  eyelid  contains 
a  layer  of  unstriated  muscle  fibre.  That  in  the 
upper  lid  arises  from  the  under  surface  of  the 
levator  palpebrse,  and  is  attached  to  the  tarsal 
cartilage  near  its  upper  margin  (Fig.  20,  p.  81). 
This  layer  of  muscle,  which,  when  in  action, 
would  keep  up  the  lid,  is  under  the  influence  of 
the  cervical  sympathetic.  The  recession  of  the 
globe  is  supposed  by  some  to  be  due  to  paralysis 
of  the  orbitalis  muscle.  This  muscle  bridges 
over  the  inferior  orbital  fissure,  is  composed 
of  unstriated  fibres,  and  is  innervated  by  the 
sympathetic.  Contraction  of  the  muscle  (as  pro- 
duced by  stimulation  of  the  cervical  sympathetic 
in  animals)  causes  protrusion  of  the  globe,  while 
section  of  the  sympathetic  in  the  neck  produces 
retraction  of  the  eyeball  (Claude  Bernard).  No 
changes  are  observed  in  the  calibre  of  the  blood- 
vessels of  the  globe.  The  non-striated  muscle 
maintains  the  intraorbital  pressure,  and  thus 
assists  in  the  return  of  blood  from  the  ophthalmic 
veins.  In  animals  such  as  the  ox,  in  which  the 
veins  of  the  orbit  become  dilated  when  the  head 
is  carried  low,  as  in  browsing,  this  musculature 
attains  a  great  development. 

THE  EYEBALL 

The  cornea.— The  thickness  of  the  cornea 
varies  from  0'9  mm.  in  the  central  parts  to 
1-1  mm.  at  the  periphery.  One  is  apt  to  be  a 
little  deceived  as  to  its  thickness,  and  on  intro- 
ducing a  knife  into  the  cornea,  the  instrument, 
if  not  entered  at  the  proper  angle,  may  be  thrust 
for  some  little  distance  among  the  laminae  of  the 
part.  In  front  the  cornea  is  covered  by  stratified 
epithelium.  When^  this  layer  has  been  removed 
by  abrasion,  a  white  deposit  of  lead  salts  may 
take  place  in  the  exposed  cornea!  tissue  in  cases 


IV] 


THE   EYEBALL 


65 


where  lead  lotions  are  used.  The  bulk  of  the 
cornea  is  made  up  of  a  great  number  of  fibrous 
lamellae,  between  which  are  anastomosing  cell 
spaces  containing  the  corneal  corpuscles.  If  the 
nozzle  of  a  fine  syringe  be  thrust  into  the  corneal 
tissue,  the  network  of  lymph-spaces  can  be  filled 
with  injection.  When  suppuration  takes  plaice 
within  the  proper  corneal  tissue,  it  is  probably 


INA  CHOP, 


CANAL  OF  SCH ' 


f~OVEA    CEHTRALIS 


OPTIC   DISC 


FtlJ-RATION  ANCLE 


OPTIC   NERVE. 

HYALOID   CAKAL 


Fig.  18. — Horizontal  section  of  the  eyeball,  showing  the 
suspensory  ligament  of  the  lens,  the  aqueous  and 
vitreous  chambers,  entrance  of  the  optic  nerve,and 
the  fovea  centralis.  (After  Schaffer.} 

along  these  canals,  modified  by  inflammation, 
that  the  pus  spreads,  thus  producing  onyx.  The 
cornea  contains  no  trace  of  blood-vessels,  except 
at  its  extreme  periphery,  where  the  capillaries 
of  the  sclerotic  and  conjunctiva  end  in  loops. 
When  inflamed,  the  tissue  always  becomes  opaque. 
In  the  affection  known  as  interstitial  keratitis, 
blood-vessels  from  the  arteries  of  the  margin  of 
t> 


60  THE    HEAD    AND    NECK  [CHAP. 

the  cornea  penetrate  into  the  substance  of  the 
cornea  for  some  distance.  As  liiese  vessels  are 
some  little  way  below  the  surface,  and  are 
covered  by  the  hazy  ccrneal  tissue  that  is  the 
result  of  the  disease,  their  scarlet  colour  is  much 
toned  down,  and  a  strand  of  such  vessels  is  called 
a  "salmon  patch."  In  the  condition  known  as 
pannus,  the  cornea  appears  to  be  vascularized ; 
but  here,  owing  to  continued  irritation,  vessels, 
derived  from  the  neighbouring  conjunctiva! 
arteries,  pass  over  the  cornea  just  beneath  its 
epithelial  covering,  leaving  the  cornea  proper  as 
bloodless  as  ever.  The  term  arcus  senilis  is  ap- 
plied to  two  narrow  white  crescents  that  appear 
at  the  periphery  of  the  cornea,  just  within  its 
margin,  in  the  aged,  and  in  certain  morbid  con- 
ditions. They  are  due  to  fatty  degeneration  of 
the  corneal  tissue,  and  the  change  is  most  marked 
in  the  layers  of  the  cornea  just  beneath  the 
anterior  elastic  lamina,  i.e.  in  the  part  most 
influenced, by  the  marginal  blood-vessels.  In  spite 
of  its  lack  of  a  direct  blood  supply,  wounds  of 
the  cornea  heal  kindly. 

The  cornea  is  very  lavishly  supplied  with 
nerves,  estimated  to  number  from  forty  to 
forty-five.  They  are  derived  from  the  ciliary 
nerves,  enter  the  cornea  through  the  fore  part 
of  the  sclerotic,  and  are  distributed  to  every 
part  of  the  tunic.  These  nerves  are  not  sensitive 
to  touch,  heat,  or  cold,  only  to  painful  stimuli. 
In  glaucoma,  a  disease  of  which  the  phenomena 
depend  upon  greatly  increased  intraocular  pres- 
sure, the  cornea  becomes  anaesthetic.  This  depends 
upon  the  pressure  to  which  the  ciliary  nerves 
are  exposed  before  their  branches  reach  the 
cornea.  (See  also  Nerve  Supply  of  the  Eyeball, 
p.  71.) 

Sclera,  clioroicl,  ami  iris.  — The  sclera  or 
sclerotic  is  thickest  behind,  and  thinnest  about 
\  of  an  inch  from  the  cornea.  When  the  globe 
is  ruptured  by  violence  it  is  the  sclerotic  that 
most  commonly  yields,  the  rent  being  usually  a 


iv]  SOLERA   AND   CHOROID  67 

little  way  from  the  cornea,  i.e.  in  or  about  the 
thinnest  part  of  the  tunic.  The  sclerotic  may 
be  ruptured  while  the  lax  conjunctiva  over  it 
remains  untorn.  In  such  a  case  the  lens  may 
escape  through  the  rent  in  the  sclera,  and  be 
found  under  the  conjunctiva.  At  the  point  of 
penetration  of  the  optic  nerve  the  sclera  is 
thin,  and  pierced  by  numerous  holes  for  the  pas- 
sage of  nerve  bundles.  This  weakened  portion, 
the  lamina  cribrosa,  plays  an  important  part  in 
glaucoma  (p.  78).  It  gives  the  stippled  appear- 
ance to  the  optic  papilla.  Brailey  states  that 
the  lateral  parts  of  the  sclera  are  thinner  than 
the  upper  and  lower  segments,  the  inferior  part 
being  the  thickest  and  the  external  wall  the  thin- 
nest. It  happens,  therefore,  that  under  the  influ- 
ence of  intraocular  pressure  the  eye  expands  more 
laterally  than  in  the  vertical  direction.  It  is 
mainly  to  the  denseness  and  unyielding  character 
of  the  sclerotic  that  must  be  ascribed  the  severe 
pain  (due  to  pressure  on  nerves)  experienced  in 
those  eye  affections  associated  with  increased  intra- 
ocular tension  (glaucoma,  etc.). 

The  choroid  is  the  vascular  tunic  of  the  globe, 
and  carries  its  main  blood-vessels.  Between  the 
choroid  and  sclera  are  two  thin  membranes,  the 
lamina  suprachoroidea  and  lamina  fusca,  which 
are  separated  from  one  another  by  a  lymph 
space.  In  injuries  to  the  globe,  therefore,  ex- 
tensive bleeding  may  take  place  between  these  two 
coats,  and  indeed  a  like  haemorrhage  may  ^be  the 
result  simply  of  a  sudden  diminution  in  the 
ocular  tension  produced  by  such  an  operation  as 
iridectomy  or  cataract  extraction.  The  choroid 
alone  has  been  ruptured  (usually  at  its  posterior 
part)  as  the  result  of  a  blow  upon  the  front  of 
the  eye.  The  choroid  is  one  of  the  few  parts  of 
the  body  that  may  be  the  seat  of  melanotic 
growths.  These  growths  are  sarcomatous  tumours 
containing  a  large  amount  of  pigment,  and  occur 
only  where  pigment  cells  are  found.  In  the 
choroid  coat  pigment  cells  arc  very  abundant. 


68  THE    HEAD    AND    NECK  [CHAP. 

The  iris  is  very  vascular,  and  liable  to  be  the 
site  of  inflammation  (iritis).  From  its  relations  to 
the  cornea  and  sclera  it  happens  that  inflammation 
in  those  tunics  can  spread  without  difficulty  to  the 
iris.  On  the  other  hand,  the  vessels  of  the  iris  and 
choroid  are  so  intimately  related  that  inflamma- 
tions set  up  in  the  iris  itself  have  every  induce- 
ment to  spread  to  the  choroidal  tunic.  When  the 
iris  is  inflamed  its  colour  becomes  altered,  owing 
to  the  congestion  of  the  part  and  to  the  effusion  of 
lymph  and  serum  that  takes  place  in  its  substance. 
The  swelling  to  which  it  becomes  subject,  together 
with  the  effusion,  produce  a  blurring  of  its  delicate 
reticulated  structure,  as  seen  through  the  cornea. 
Owing  also  to  the  swollen  condition  of  the  little 
membrane,  the  pupil  becomes  encroached  on, 
and  appears  to  be  contracted,  while  the  move- 
ments of  the  membrane  are  necessarily  rendered 
very  sluggish.  If  it  be  remembered  that  part 
of  the  posterior  surface  of  the  iris  is  in  actual 
contact  with  the  lens  capsule,  it  will  be  understood 
that  inflammatory  adhesions  may  readily  take 
place  between  the  two  parts  (Fig.  18).  After  iritis, 
therefore,  it  is  common  to  find  the  posterior  sur- 
face of  the  iris  (most  often  its  pupillary  margin) 
adherent  to  the  lens  capsule  by  bands  of  lymph, 
either  entirely  or  in  one  or  more  different  points. 
Such  adhesions  constitute  posterior  synechise,  the 
term  anterior  synechise  being  applied  to  adhesions 
between  the  iris  and  the  cornea.  In  iritis  also  the 
lens  may  become  involved,  and  the  condition  of 
secondary  or  inflammatory  cataract  be  produced. 

The  iris  is  not  very  closely  attached  at  its 
insertion  (Fig.  19).  Thus, .in  the  case  of  injury 
to  the  eye,  it  may  be  torn  more  or  less  from 
its  attachments  without  any  damage  being  done 
to  the  other  tunics.  The  iris  has  been  com- 
pletely torn  away  in  a  few  instances,  and  has 
escaped  through  a  wound  of  the  globe.  The  ciliary 
processes  have  been  thus  exposed.  Congenital 
absence  of  the  iris  has  been  recorded.  In  cases 
of  penetrating  wounds  of  the  cornea  the  iris  may 


iv]  THE   IRIS  69 

easily  become  prolapsed.  It  is  so  delicate  and  yield- 
ing a  membrane  that  in  performing  iridectomy  the 
necessary  piece  of  the  iris  can  be  seized  and  pulled 
out  through  the  corneal  incision  without  offering 
sensible  resistance.  The  membrane  also  derives 
much  support  from  its  contact  with  the  lens,  for 
in  cases  where  the  lens  has  been  displaced  into  the 
vitreous,  or  has  been  removed  by  operation,  the 
iris  is  observed  to  be  tremulous  when  the  globe  is 
moved.  Although  very  vascular,  the  iris  seldom 
bleeds  much  when  cut,  a  circumstance  that  is  prob- 
ably due  to  the  contraction  of  the  muscular  fibres 
that  exist  so  plentifully  within  it.  Sometimes  the 
iris  presents  in  its  substance  a  congenital  gap  that 
runs  from  the  pupil  downwards  and  a  little  in- 
wards. This  condition  is  known  as  coloboma  iridis, 
and  is  due '  to  the  persistence  of  the  "  choroidal 
cleft"  formed  during  development  of  the  optic 
cup.  In  other  cases  there  can  be  seen,  stretch- 
ing across  the  pupil,  some  shreds  of  the  pupillary 
membrane.  This  membrane,  which  is  apparent 
for  a  few  days  after  birth  in  some  animals,  is 
entirely  absorbed  long  before  birth  in  the  human 
species. 

It  will  now  be  convenient  to  take  note  of  the 
blood  and  nerve  supply  of  the  globe. 

Blood  supply  of  the  eyeball.— 1.  The 
short  ciliary  arteries  (from  the  ophthalmic)  pierce 
the  sclera  close  to  the  optic  nerve,  run  some  little 
way  in  the  outer  coat  of  the  choroid,  and  then 
break  up  into  a  capillary  plexus  that  makes  up  the 
main  part  of  the  inner  choroidal  coat.  In  front  this 
plexus  gives  some  vessels  to  the  ciliary  processes. 
The  veins  from  these  vessels  are  disposed  in  curves 
as  they  converge  to  four  or  five  main  trunks  (vense 
vorticosse),  which  pierce  the  sclera  midway  be- 
tween the  cornea  and  the  optic  nerve.  In  the 
choroid  they  lie  externally  to  the  arteries. 

2.  The  two  long  ciliary  arteries  (from  the 
ophthalmic)  pierce  the  sclera  to  the  outer  side 
of  the  op^tic  nerve  and  run  forwards,  one  on  either 
side,  until  they  reach  the  ciliary  region,  where  they 


70  THE    HEAD    AND    NECK  [CHAP. 

break  up  into  branches  that,  by  anastomosing, 
form  a  vascular  circle  about  the  periphery  of  the 
iris  (the  circulus  major).  From  this  circle  some 
branches  pass  to  the  ciliary  muscle,  while  the  rest 
run  in  the  iris  in  a  converging  manner  towards  the 
pupil,  and  at  the  margin  of  the  pupil  form  a 
second  circle  (the  circulus  minor). 

3.  The  anterior  ciliary  arteries  (from  the  mus- 
cular and   lacrimal  branches  of  the  ophthalmic) 
pierce  the  sclerotic  (perforating  branches)  about 
2  to  3  mm.   behind  the  cornea,   join  the  circulus 
major,   and  give  off  branches  to  the  ciliary  pro- 
cesses,   where    they    form    copious    anastomosing 
loops.     These  arteries   lie  in  the   subconjunctival 
tissue.  Their  episcleral  or  non-perforating  branches 
are  very   small  and  numerous,   and  are  invisible 
in  the  normal  state  of  the  eye.     In  inflammation 
of  the  iris  and  adjacent  parts,  however,  these  ves- 
sels appear  as  a  narrow  pink  zone  of  fine  vessels 
round  the  margin  of  the  cornea,  that  run  nearly 
parallel  to  one  another,  are  very  closely  set,  and 
do  not  move  with  the  conjunctiva.     This  zone  is 
known  as  the  zone  of  ciliary  congestion,   or  the 
circumcorneal  zone. 

4.  The  vessels  of  the  conjunctiva  are  derived 
from  the  lacrimal  and  the  two  palpebral  arteries. 
These  vessels,  in  cases  of  inflammation,  are  readily 
distinguished  from  those  last  described.    They  are 
of  comparatively  large  size,  are  tortuous,  are  of  a 
bright  brick-red  colour,  can  be  easily  moved  with 
the   conjunctiva,   and   as  easily   emptied  of  their 
blood  by  pressure.     The  differences  presented  by 
these^two  sets  of  vessels  serve  in  one  way  to  dis- 
tinguish inflammation  of  the  conjunctiva  from  that 
involving  deeper  parts.     The  conjunctival  vessels 
around  the  margin   of  the  cornea  form  a   closer 
plexus  of  anastomosing  capillary  loops,  which  be- 
come congested  in  severe  superficial  inflammation 
of  the  cornea,  and  may  then  form  a  zone  around 
the  margin  of  the  cornea,  which  can,  however,  be 
distinguished    from    the    "ciliary    zone"    by    the 
general  characters  just  named. 


iv]  VESSELS   OF  THE   EYEBALL  71 

The  retina  has  a  vascular  system  of  its  own, 
supplied  through  the  arteria  centralis  retinae, 
which  is  nowhere  in  direct  communication  with 
the  choroidal  vessels,  except  just  at  the  entrance 
of  the  optic  nerve.  Indeed,  the  outer  layers  of 
the  retina  which  are  in  relation  with  the  choroid 
coat  are  entirely  destitute  of  vessels.  Thus,  when 
the  central  artery  of  the  retina  becomes  plugged, 
sudden  blindness  follows,  and,  as  the  meagre 
collateral  circulation  that  is  established  by  the 
minute  anastomoses  about  the  entrance  of 
the  nerve  is  quite  insufficient,  the  retina  soon 
becomes  oedematous.  A  permanent  plugging  of 
the  central  artery  means,  therefore,  a  practical 
extinction  of  the  vascular  system  of  the  retina. 
In  some  cases  of  embolism,  only  a  branch  of  the 
retinal  artery  is  plugged,  the  patient  retaining 
vision  except  in  that  part  of  the  retina  supplied 
by  the  branch.  The  fovea  centralis,  the  centre  of 
acute  vision,  receives  twigs  from  both  the  superior 
and  inferior  temporal  branches  of  the  arteria 
centralis  retinae. 

In  cases  of  haemorrhage  between  the  choroid 
and  retina  the  blood  must  come  from  the  choroidal 
vessels ;  and  in  haemorrhage  into  the  vitreous, 
which  often  follows  injury,  the  blood  may  be  de- 
rived from  the  retinal  vessels,  since  they  run  in  the 
inner  layers  of  that  membrane,  or  from  the  vessels 
in  the  ciliary  region. 

Nerve  supply  of  tlie  eyeball. — l.  The  cili- 
ary nerves,  derived  from  the  ciliary  (lenticular) 
ganglion  and  the  nasal  (naso-ciliary)  nerve,  pierce 
the  sclerotic  close  to  the  optic  nerve,  and  pass 
forwards  between  the  sclerotic  and  the  choroid, 
supplying  those  parts.  They  enter  the  ciliary 
muscle,  form  a  plexus  about  the  periphery  of 
the  iris,  and  then  send  fibres  into  the  iris,  which 
form  a  fine  plexus  as  far  as  the  pupil.  They 
send  branches  through  the  fore  part  of  the  sclerotic 
to  the  cornea.  Thus  the  eyeball  obtains  through 
these  nerves  its  sensory  fibres  from  the  nasal  or 
naso-ciliary  branch  of  the  first  division  of  the 


72  THE    HEAD    AND    NECK  [CHAP. 

fifth,  its  motor  fibres  for  the  ciliary  muscle  and 
sphincter  iridis  from  the  third  nerve,  and  many 
sympathetic  fibres,  among  which  are  those  that 
supply  the  dilator  muscle  of  the  iris  (see  p.  64). 

2.  The  conjunctiva  is  supplied  by  four  nerves  : 
above,  the  supratrochlear;  inner  side,  the  infra- 
trochlear;  outer  side,  the  lacrimal  (all  branches 
of  the  first  division  of  the  fifth) ;  below,  the  palpe- 
bral  branches  of  the  second  division  of  the  fifth. 
As  the  ciliary  nerves  pass  forwards  between  the 
choroid  and  the  sclerotic,  it  will  be  seen  that  they 
are  readily  exposed  to  injurious  pressure  against 
the  unyielding  sclerotic  in  cases  of  increased  intra- 
ocular tension. 

The  sensation  of  the  globe  itself  is  derived  solely 
from  the  first  division  of  the  fifth.  In  inflammatory 
affections  of  the  globe,  as  in  corneitis  or  iritis,  be- 
sides the  pain  actually  felt  in  the  eye,  there  is 
pain  referred  along  other  branches  of  the  first 
division  of  the  fifth.  The  explanation  of  this  fact 
has  to  be  sought  for  in  the  common  origin  of 
the  ophthalmic  division  from  the  upper  sensory 
nucleus  of  the  fifth  nerve  in  the  floor  of  the  fourth 
ventricle.  Not  only  are  the  nerve  cells  connected 
with  the  eyeball  disturbed,  but  the  neighbouring 
cells  also  are  affected,  and  by  a  psychical  error 
the  pain  is  reflected  along  the  nerves  with  which 
these  neighbouring  cells  are  connected.  There  is 
pain  over  the  forehead  along  the  supratrochlear, 
the  supraorbital,  and  the  lacrimal  branches  (cir- 
cumorbital  pain),  and  pain  down  the  side  of  the 
nose  following  the  nasal  nerve.  Or  the  pain  may 
spread  to  the  second  division  of  the  fifth,  and 
discomfort  be  felt  in  the  temporal  region  (orbital 
branch  of  the  second  division),  or  be  referred  to 
the  upper  jaw  and  teeth.  These  affections,  too, 
are  associated  with  much  lacrimation,  the  lacri- 
mal gland  being  also  supplied  through  the  first 
division  of  the  fifth.  Photophobia,  or  intoler- 
ance of  light,  is  common  in  inflammatory  affec- 
tions of  the  eye.  In  this  condition  there  is  spasm 
pf  the  orbicular  muscle,  keeping  the  eye  closed, 


iv]  NERVES   OF   THE   EYEBALL  73 

or  closing  it  on  the  least  exposure  to  irritation. 
Although  the  orbicular  muscle  is  supplied  by  the 
facial  nerve,  its  nerve  fibres  are  derived,  not  from 
the  nucleus  of  the  seventh  but  from  the  oculo- 
motor nucleus,  situated  near  the  upper  sensory 
nucleus  of  the  fifth,  and  connected  with  it  by 
reflex  paths.  Photophobia  is  most  marked  in 
superficial  affections  of  the  cornea,  and  is  often 
much  benefited  by  a  seton  in  the  temporal  region. 
Inflammation  of  the  iris  and  glaucoma  are  accom- 
panied by  hypersesthesia  and  referred  pains  over 
the  outer  frontal  and  anterior  temporal  areas 
(Head).  The  nerve-centres  for  the  skin  of  this 
region  and  the  eyeball  are  closely  connected,  a 
relationship  which  may  explain  the  application 
of  counter-irritation  to  the  temples  in  eye  disease. 
Inflammation  of  the  cornea  gives  rise  to  no 
referred  pains  (Head).  Strain  of  the  ciliary 
muscle,  which  occurs  with  errors  of  refraction,  is 
one  of  the  commonest  causes  of  headache,  leading 
to  referred  pains  and  areas  of  hypersesthesia  over 
the  midorbital  region  of  the  forehead. 

The  relations  between  the  nasal  (naso-ciliary) 
nerve  and  the  orbital  contents  receive  many 
illustrations  in  practice.  Thus,  if  the  front  of 
the  nose  be  struck,  or  the  skin  over  its  lower 
part  be  irritated,  as  by  squeezing  a  painful 
boil,  profuse  lacrimatiori  will  frequently  be 
produced.  Snuff,  too,  by  stimulating  the  nasal 
branch  of  the  ophthalmic  nerve,  often  makes 
the  eyes  of  the  uninitiated  to  water ;  and  it  is 
well  known  that  there  are  many  disturbances 
about  the  nose,  and  the  anterior  part  of  the 
nasal  fossae,  that  can  "make  the  eyes  water." 
Herpes  zoster  often  provides  a  remarkable  illus- 
tration of  the  intimate  relation  between  the  nasal 
nerve  and  the  eye.  In  this  affection,  when  the 
regions  of  the  supraorbital  and  supratrochlear 
branches  of  the  first  division  are  alone  implicated, 
the  eye  is  usually  unaffected;  but  when  the  erup 
tion  extends  over  the  part  supplied  by  the  nasal 
nerve,  i.e.  runs  down  the  side  of  the  nose,  then 


74  THE    HEAD    AND    NECK  [CHAP. 

there  is  very  commonly  some  inflammation  of  the 
eyeball. 

Dangerous  area  of  the  eye. — Penetrating 
wounds  of  the  cornea  alone,  or  of  the  sclera 
alone,  behind  the  ciliary  region,  are  by  no  means 
serious ;  but  wounds  involving  the  ciliary  body, 
or  its  immediate  vicinity,  are  apt  to  assume^  the 
gravest  characters.  Inflammation  in  the  ciliary 
region  is  peculiarly  dangerous,  on  account  of  the 
important  vascular  and  nerve  anastomoses  that 
take  place  in  the  part.  Indeed,  as  regards  blood 
and  nerve  supply,  there  is  no  more  important 
district  in  the  eyeball.  From  the  ciliary  body 
also  inflammations  can  spread,  more  or  less 
directly,  to  the  cornea,  iris,  chproid,  vitreous,  and 
retina.  Plastic,  or  purulent,  inflammation  of  the 
ciliary  body,  after  injury,  is  the  usual  starting- 
point  'of  sympathetic  ophthalmia.  ^  In  this  terrible 
affection  destructive  inflammation  is  set  up  in  the 
opposite  sound  eye,  which  is,  however,  not  usually 
involved  until  two  or  three  months  after  the  other 
eye  has  been  injured.  It  is  now  generally  believed 
that  the  sound  eye  is  directly  infected  from  the 
diseased  one.  The  subarachnpid  spaces  which  sur- 
round the  optic  nerves  are-  in  continuity  at  the 
chiasma,  and  offer  a  path  whereby  infection  may 
spread  from  one  eye  to  the  other. 

The  lens  measures  £  of  an  inch  from  side  to 
side,  and  £  of  an  inch  from  before  backwards. 
All  through  life  it  slowly  increases  in  size.  It, 
together  with  its  capsule,  is  in  all  parts  per- 
fectly transparent  and  perfectly  non-vascular. 
The  manner  in  which  the  lens  is  maintained  in 
position  is  shown  in  Figs.  18  (p.  65)  and  19 
(p.  77).  The  circumference  of  the  lens  is  fixed 
to  the  ciliary  processes  by  a  system  of  fine, 
transparent,  radial  fibres  (the  suspensory  liga- 
ment of  the  lens),  some  of  which  pass  in  front 
of  the  lens,  while  others  pass  behind  it,  thus 
forming  a  sac  or  capsule  for  the  lens.  On  the 
ciliary  processes  the  radial  fibres  of  the  sus- 
pensory ligament  become  continuous  with  the 


iv]  LENS   AND   RETINA  75 

transparent  capsule  of  the  vitreous  humour— 
the  hyaloid  membrane.  The  lens  may  easily 
be  loosened  or  displaced  by  partial  rupture  of 
its  suspensory  ligament,  and  may  find  its  way 
into  the  anterior  chamber,  or,  more  commonly, 
back  into  the  vitreous.  If  disturbed,  the  lens 
may  swell,  and  by  the  pressure  thus  exercised 
cause  great  damage  to  the  important  structures 
adjacent  to  it.  The  capsule  is  very  brittle  and 
elastic,  and  when  torn  its  edges  curl  outwards. 
It  is  lacerated  in  the  usual  operations  for  cataract, 
and  may  be  ruptured  by  many  forms  of  violence 
applied  to  the  eyeball.  "  In  one  form  of  cataract 
operation  the  capsule  is  removed  with  the  lens, 
the  vitreous  being  retained  in  position  by  the 
hyaloid  membrane  which  lies  behind  the  capsule 
of  the  lens"  (Lieut. -Colonel  H.  Smith).  When  the 
capsule  is  wounded  the  aqueous  humour  enters, 
and  is  imbibed  by  the  lens  fibres,  which  in  conse- 
quence swell  up  and  become  opaque,  thus  produc- 
ing a  traumatic  cataract.  In  the  various  forms  of 
cataract  the  whole  lens,  or,  more  commonly,  some 
portion  of  it,  becomes  the  seat  of  opacity.  This 
often  commences  in  the  nucleus,  and  for  a  long 
while  remains  limited  to  that  part;  or  it  may 
first  involve  the  cortex,  and  in  such  a  case 
the  opacity  takes  the  form  of  a  series  of  streaks 
that  point  towards  the  axis  of  the  lens,'  and 
are  dependent  upon  the  arrangement  of  the  lens 
fibres. 

Of  the  retina  it  is  only  necessary^  to  observe 
that  its  connexion  with  the  choroid  is  so  slight 
that  it  may  easily  be  detached  from  that  mem- 
brane by  hsemorrhagic  or  other  effusions,  and  may 
indeed  be  so  detached  by  a  simple  blow  upon  the 
globe.  Even  when  extensively  detached  it  remains, 
however,  #s  a  rule,  attached  at  both  the  optic  disc 
and  the  or  a  serrata. 

The  length  of  the  optic  nerve  within  the  orbit 
is  28-30  mm.  As  it  passes  from  the  brain  it 
receives  its  perineural  sheath  from  the  pia 
mater,  and,  in  addition,  two  other  sheaths  :  an 


76  THE    HEAD    AND    NECK  [CHAP. 

outer  from  the  dura  mater,  and  an  inner  from 
the  arachnoid.  These  sheaths  remain  distinct  and 
separate,  and  the  two  spaces  enclosed  may  be  in- 
jected, the  outer  from  the  subdural,  the  inner  from 
the  subarachnoid  space.  Thus  inflammatory  affec- 
tions of  the  cerebral  meninges  can  readily  extend 
along  the  optic  nerve  to  the  optic  disc  through 
these  spaces  in  the  nerve  sheath,  while  in  cases  of 
intracranial  disease  other  than  meningeal  the 
mischief  may  extend  from  the  brain  to  the  disc 
along  the  interstitial  connective  tissue  in  the  n^rve. 
These  connexions  may  serve  in  part  to  explain  the 
frequent  association  of  optic  neuritis  with  intra- 
cranial disease.  As  the^nerve  leaves  the  skull  in 
the  optic  foramen  it  is  in  contact  with  the  outer 
wall  of  the  sphenoidal  sinus,  or,  if  that  sinus 
be  relatively  small,  with  the  posterior  ethmoidal 
cells.  In  suppuration  of  these  spaces  infection 
may  spread  to  the  optic  nerve,  and  thus  set  up 
optic  neuritis.  When  the  intracranial  pressure 
is  raised  by  the  growth  of  a  tumour,  haemor- 
rhage, or  other  condition  within  the  skull,  that 
pressure  is  exerted  on  the  optic  nerve,  thus 
interfering  with  a  free  circulation  along  the 
nerve,  and  leading  to  a  change  in  the  appearance 
of  the  optic  disc. 

Aqueous  and  vitreous  humours.  —  The 
aqueous  fills  the  anterior  chamber,  the  space  between 
the  capsule  and  suspensory  ligament  of  the  lens  and 
the  cornea.  The  iris  divides  this  space  into  two 
parts,  the  anterior  and  posterior.  Since,  however, 
the  iris  is  largely  in  actual  contact  with  the  lens, 
is  happens  that  the  posterior  part  is  repre- 
sented by  a  little  angular  interval  between  the 
iris,  the  ciliary  processes,  and  the  suspensory 
ligament  of  the  lens  (Fig.  19).  The  depth  of  the 
anterior  chamber  is  3'6  mm.  The  innej  stratum 
of  the  cornea,  as  it  becomes  continuous  with 
the  sclera,  splits  up  into  fibres  which  pass  to 
(1)  the  sclera,  (2)  the  ciliary  muscle,  (3)  the  cili- 
ary processes.  The  fibres  form  the  ligament  um 
pectinatum,  and  the  intervals  between  its  fibres 


IV] 


AQUEOUS   HUMOUR 


77 


are  known  as  the  spaces  of  Fontana  (iridio-corneal 
spaces).  They  are  filled  by  the  aqueous  humour. 
The  fluid  in  these  spaces  is  absorbed  into  a 
circular  canal  in  the  sclera — the  circular  venous 
canal,  or  canal  of  Schlemm  (see  Fig.  19).  This 
canal  is  in  communication  with  the  veins  of  the 
anterior  part  of  the  sclerotic,  ciliary  processes, 
and  iris.  The  aqueous  humour  is  being  con- 
stantly secreted  by  the  ciliary  processes  behind 


CONJUNCTIVA 

CANAL  OF  SCHLEMM 
PECTINATE  LIQ. 
CILIARY  Muse. 


LENS 


Fig.    19. — Ligamentum    pectinatum,  spaces   of    Fontana, 
ciliary  muscle,  and  capsule  of  the  lens. 

the  iris,  and  equally  constantly  absorbed  into 
the  canal  of  Schlemm,  thence  passing  into  the 
venous  circulation.  The  tension  of  the  eyeball 
is  maintained  by  an  exact  regulation  between 
the  rates  of  secretion  and  absorption.  Thus, 
if  pus  finds  its  way  into  the  anterior  chamber 
(hypopyon)  it  is,  as  a  rule,  easily  absorbed.  The 
same  applies  to  moderate  extravasations  of  blood 
in  the  chamber,  and  the  speedy  removal  of  such 
effusions  contrasts  with  the  difficulty  that  is 


78  THE    HEAD    AND    NEGK  [CHAP. 

experienced  in  the  absorption  of  blood  from  the 
vitreous  chamber. 

Prof.  Arthur  Thomson  has  shown  that  the 
inner  aspect  of  the  sclera  is  depressed  or  grooved 
at  the  anterior  base  of  the  iris.  When  the  pupil 
is  dilated  the  contracted  base  of  the  iris  tends 
to  fill  this  groove,  thus  rendering  the  escape  of 
the  aqueous  humour  into  the  spaces  of  Fontana 
more  difficult. 

The  vitreous  takes  little  active  share  in  ocular 
maladies.  It  may  be  secondarily  affected  in  in- 
flammation of  adjacent  parts,  may  be  the  seat  of 
haemorrhages,  and  is  often  occupied  by  opaque 
bodies  of  various  kinds.  Foreign  bodies  have  lodged 
in  the  vitreous  for  considerable  periods  without 
causing  any  symptoms.  The  muscse  volitantes  that 
so  often  trouble  the  myopic  are  due  to  little 
opaque  particles  in  the  vitreous,  and  very  often 
have  exactly  the  appearance  that  the  corpuscles 
of  the  vitreous  present  when  seen  under  the 
microscope. 

The  delicate  transparent  membrane  which  en 
capsules  the  vitreous  humour  is  known  as  the 
hyaloid  membrane.  The  vitreous  is  readily  separ- 
ated from  the  retina,  except  behind,  opposite  the 
disc  where  the  artery  to  the  lens  enters  in  the 
foetus  and  passes  forwards,  in  the  hyaloid  canal, 
to  supply  the  fcetal  pupillary  membrane.  This 
vessel  is  a  branch  of  the  central  artery  of  the 
retina,  and  may  persist  as  a  fibrous  cord  in  adult 
life.  In  some  rare  cases  it  has  continued  to 
transmit  blood,  and  in  such  instances  its  pulsation 
can  be  seen  with  the  ophthalmoscope. 

Olaucoma  is  a  disease  the  symptoms  of  which 
are  all  dependent  upon  an  increase  in  the  intra- 
ocular tension  of  the  globe.  When  the  pressure 
within  the  eyeball  rises  above  the  pressure  of  the 
blood  in  the  arterioles  of  the  retina  and  choroid, 
then  the  nutrition  of  the  eye  ceases.  Normally  the 
intraocular  tension  is  equal  to  that  of  the  blood  in 
the  intraocular  veins.  If  there  is  a  failure  in 
absorption  of  the  aqueous  humour  into  the  circular 


iv]  GLAUCOMA  79 

venous  canal  of  the  sclera,  then  pressure  rises.  The 
condition  is  the  same  as  in  the  brain ;  the  aqueous 
humour  of  the  eye  represents  the  cerebro-spinal 
fluid  of  the  brain.  It  is  remarkable  that  in  nearly 
every  case  of  glaucoma  the  spaces  of  Fontana  are 
occluded  by  the  complete  obliteration  of  the  angle 
between  the  periphery  of  the  iris  and  the  cornea, 
which  angle  is  normally  occupied  by  the  ligamen- 
tum  pectinatum. 

The  importance  of  the  peripheral  part  of  the 
anterior  chamber  in  relation  to  the  outflow  of 
fluid  from  the  eye  is  shown  in  many  ways.  If 
this  part  be  blocked  by  the  iris  in  perforation 
of  the  cornea,  or  by  the  lens  in  some  disloca- 
tions of  that  body,  increased  tension  of  the  globe 
is  apt  to  follow.  The  relief  given  to  glaucoma  by 
iridectomy  appears  to  depend  upon  the  circum- 
stance that  the  operation  practically  opens  up 
again  these  channels  of  communication  from  the 
aqueous,  since  the  procedure,  to  be  successful, 
should  involve  an  incision  so  far  back  on  the  sclera 
as  fully  to  pass  through  the  angle  just  alluded 
to.  It  is  needful  also  that  the  iris  should  be  re- 
moved quite  up  to  its  attachment,  and  that  the 
portion  resected  should  be  considerable.  Iridec- 
tomy also  exposes  a  fresh  capillary  surface  of 
the  iris  to  the  aqueous  humour,  which  thus  finds 
a  fresh  exit.  In  the  young  the  ligamentum 
pectinatum  is  cellular  and  open  in  structure ; 
it  becomes  fibrous  and  contracted  in  the  old. 
Hence  the  aged  are  more  liable  to  glaucoma  (T. 
Henderson). 

The  symptoms  of  glaucoma  are  all  explained 
by  the  effects  of  the  abnormal  tension.  Thus,  the 
ciliary  nerves  are  compressed  against  the  unyield- 
ing sclera,  and  give  rise  to  intense  pain,  while 
the  disturbance  in  their  functions  shows  itself 
in  the  fixed  and  dilated  pupil  and  in  the  anaes- 
thetic cornea.  Perhaps  the  first  parts  to  suffer 
from  compression  are  the  retinal  blood-vessels, 
and  the  effect  upon  them  will  be  most  obvious  at 
the  periphery  of  the  retina,  i.e.  at  the  extreme 


80  THE    HEAD    AND    NECK  [CHAP. 

limit  of  the  retinal  circulation.  Hence  follows 
that  gradual  narrowing  of  the  visual  field  which 
is  constant  in  glaucoma,  while  the  pressure  upon 
the  optic  nerve  produces  those  flashes  of  light 
and  other  spectra  which  occur  in  the  disease. 
The  weakest  part  of  the  sclera  is  in  the  disc 
at  the  lamina  cribrosa.  This  part  rapidly  yields 
under  the  pressure,  and  so  produces  the  "glauco- 
matous  cup."  Pressure  in  the  opposite  direction 
pushes  the  lens  forwards,  and  thus  narrows  the 
anterior  chamber;  while  the  general  interference 
with  the  ocular  circulation  is  shown  in  the  dis- 
tended vessels  that  appear  upon  the  globe. 

The  eyelids  (Fig.  20).— The  skin  over  the  eye- 
lids is  very  thin  and  delicate,  and  shows  readily 
through  its  substance  any  extravasation  of  blood 
that  may  form  beneath  it.  Its  laxity,  moreover, 
renders  it  very  well  adapted  for  certain  plastic 
operations  that  are  performed  upon  the  part.  Its 
loose  attachments  cause  it  to  be  readily  influenced 
by  traction,  and  the  shrinking  of  cicatrices  below 
the  lower  lid  is  very  apt  to  draw  that  fold  away 
from  the  globe,  and  so  produce  the  condition  of 
eversion  of  the  lid  known  as  ectropion.  The  con- 
traction of  the  conjunctiva  after  inflammatory  con- 
ditions, or  after  it  has  been  subjected  to  destructive 
agencies,  is  prone,  on  the  other  hand,  to  curl  either 
lid  inwards  towards  the  globe,  and  thus  to  produce 
fntropion.  The  lids  present  many  transverse 
folds  ;  one  of  these  on  the  upper  lid,  deeper  and 
more  marked  than  the  rest,  divides  the  lid  into 
two  parts,  the  part  below  being  that  which  covers 
the  globe,  the  part  above  being  that  in  relation 
with  the  soft  structures  of  the  orbit.  In  emacia- 
tion the  lid  becomes  much  sunken  in  the  line  of 
this  fold.  Incisions  should  follow  the  direction 
of  the  fold.  The  lids  are  very  freely  supplied 
with  blood,  and  are  often  the  seat  of  nsevi  and 
other  vascular  growths. 

The  following  layers  are  found  in  either  lid  in 
order:  (1)  the  skin;  (2)  the  subcutaneous  tissue; 
(3)  the  orbicularis  oculi ;  (4)  the  tarsal  plate 


IV] 


THE   EYELIDS 


81 


(superior  tarsus)  and  its  continuation  to  the  margin 
of  the  orbit — the  orbital  septum  (palpebral  mem- 
brane);  (5)  the  layer 
of  tarsal  (Meibomian) 
glands  embedded  in 
the  plate;  and  (6)  the 
conjunctiva.  In  the 
upper  lid  the  levator 
palpebrse  is  found 
passing  to  the  tarsal 
plate.  The  subcuta- 
neous tissue  is  very 
lax,  and  hence  the 
lids  swell  greatly  when 
cedematous,  or  when 
inflamed,  and  when 
the  seat  of  haemor- 
rhage. On  this  ac- 
count it  is  inadvisable 
to  apply  leeches  to  the 
lids,  because  of  the 
extensive  "black  eye" 
that  may  follow.  This 
tissue  is  peculiar  in 
containing  no  fat.  At 
the  'edge  of  the  lids 
are  found  the  eye- 
lashes, the  orifices  of 
the  tarsal  glands, 
and  of  some  modified 
sweat-  and  sebaceous 
glands.  The  secretion 
of  these  glands  pre- 
vents adhesion  of  the 
edges  of  the  lid.  This 
edge,  like  other  points 
of  junction  of  skin 
and  mucous  mem- 


Fig.      20.  —  Vertical      section 

through   upper   eyelid.      (After 

Waldeyer.) 

a,  Skin  ;  &,  orbicularis  ;  b',  its  ciliary 
part ;  c,  involuntary  muscle  of 
eyelid  representing  part  of  the 
insertion  of  the  levator  palpe- 
brse ;  d,  conjunctiva  ;  e,  superior 
tarsus;  /,  tarsal  gland;  g,  modi- 
fled  sweat-gland  ;  h,  eyelashes  : 
i,  post-tarsal  glands. 


brane,    is    apt    to    be 
the   seat  of   irritative 
affections.     As  it  is  a  free  border  also  the  circu- 
lation  is  terminal,    and   stagnation   in   the   blood 


82  THE    HEAD    AND    NECK  [CHAP. 

current  is  not  difficult  to  produce.  Sycosis,  an 
inflammation  involving  the  hair-follicles  and  some 
of  the  glands  at  the  edge  of  the  lid,  is  among 
the  most  common  of  ophthalmic  affections.  The 
common  stye  also  is  a  suppuration  in  the  con- 
nective tissue  or  in  one  of  the  glands  at  the 
margin.  On  everting  the  lid  the  tarsal  glands 
can  be  seen  through  the  conjunctiva  as  lines  of 
yellowish  granules.  The  common  tarsal  cyst  is  a 
retention  cyst  developed  in  one  of  these  glands. 

Two  arteries  supply  either  lid  :  a  palpebral 
branch  of  the  ophthalmic  running  along  the  inner 
part,  and  a  branch  of  the  lacrimal  along  the 
outer  part  of  each  lid.  Four  nerves  supply  the 
upper  eyelid,  the  supraorbital,  the  supratrochlear 
and  infratrochlear,  and  the  lacrimal.  One  nerve 
supplies  the  lower  lid,  the  infraorbital.  Some 
of  the  lymphatics  of  the  eyelids  enter  the  pre- 
auricular  glands,  hence  in  cases  of  chancre  of  the 
lid  the  glandular  enlargement  has  nearly  always 
been  noticed  in  front  of  the  parotid  gland. 

The  conjunctiva. — The  ocular  part  of  this 
membrane  is  thin,  covered  with  stratified  epithe- 
lium very  loosely  attached,  and  not  very  exten- 
sively supplied  with  blood;  the  palpebral  portion 
is  thicker,  covered  with  columnar  epithelium  more 
closely  adherent,  and  more  vascular.  At  the  edge 
of  the  cornea  the  conjunctiva  becomes  continuous 
with  the  epithelium  covering  that  tunic.  The  loose- 
ness of  the  ocular  conjunctiva  allows  it  to  be  freely 
moved  about,  and  is  of  great  value  in  some  opera- 
tions, as,  for  example,  in  Teale's  operation  for 
symblepharon,  where  a  bridge  of  conjunctiva,  dis- 
sected up  from  the  globe  above  the  cornea,  is  drawn 
down  over  the  cornea  to  coyer  a  raw  surface  in  con- 
tact with  the  lower  lid.  This  lax  tissue  favours  the 
development  of  oedema  (chemosis),  which  in  ex- 
treme cases  may  reach  such  a  degree  that  the 
patient  cannot  close  his  eye.  The  vessels  also, 
being  feebly  supported,  are  prone  to  give  way 
under  no  great  provocation.  Thus,  subconjunc- 
tival  haemorrhages  may  occur  from  severe  vomit- 


iv]  THE   CONJUNCTIVA  83 

ing,  or  during  a  paroxysm  of  whooping-cough. 
Blood  also  may  find  its  way  beneath  the  membrane 
in  fractures  of  the  base  of  the  skull.  Haemorrhages 
beneath  the  membrane  are  unlike  other  extravasa- 
tions (bruises),  in  that  they  retain  their  scarlet 
colour.  This  is.  due  to  the  fact  that  the  thinness 
of  the  conjunctiva  allows  oxygen  to  reach  the 
blood  and  gives  it  an  arterial  character.  Severe 
inflammation  of  the  conjunctiva  may  lead  to  con- 
siderable cicatricial  changes,  as  is  the  case  in  other 
mucous  membranes,  and  especially,  perhaps,  in 
the  urethra.  The  contraction  of  the  conjunctiva 
after  destructive  processes  is  apt  to  lead  to  en- 
tropion.  If  both  the  ocular  and  the  corresponding 
part  of  the  palpebral  conjunctiva  have  been  de- 
stroyed, the  two  raw  surfaces  left  will  readily  ad- 
here ;  the  lid  will  become  fused  to  the  globe,  and 
the  condition  called  symblepharon  be  produced. 
This  condition  concerns  the  lower  lid,  and  is  gener- 
ally brought  about  by  lime  or  other  caustics  being 
accidentally  introduced  between  the  under  lid 
and  the  globe. 

In  one  common  form  of  inflammation  of  this 
membrane  a  number  of  little  "  granulations  "  ap- 
pear upon  the  palpebral  conjunctiva.  These  are 
not  real  granulations,  since  no  true  ulceration  of 
the  part  takes  place,  but  they  appear  to  be  made 
up,  some  of  nodules  of  adenoid  tissue,  others^  of 
gnlarged  mucous  follicles  and  of  hypertrophied 
papillae,  all  of  which  structures  are  normally  found 
in  the  membrane.  The  condition  is  known  as 
"granular  lids," and  is  associated  with  the  form- 
ation of  much  new  tissue  in  the  deeper  parts  of 
the  membrane.  From  the  absorption  of  this  new 
tissue  and  of  these  granulations  a  contracting 
cicatrix  results,  leading  to  much  puckering  of  the 
membrane,  and  often  to  entropion  and  inversion 
of  the  eyelashes. 

liacrimal  apparatus. — The  lacrimal  gland, 
which  is  situated  in  the  upper  and  outer  quadrant 
of  the  orbit  (Fig.  21),  is  separated  by  the  lateral 
expansion  of  the  tendon  of  the  levator  palpebrae 


84  THE    HEAD    AND    NECK  [CHAP. 

into  two  parts— a  large  superior,  lying  between 
the  expansion  and  the  roof  of  the  orbit,  and  a 
small  inferior,  which  lies  between  the  expansion 
and  the  reflection  of  the  conjunctiva  from  the 
eyeball  to  the  upper  eyelid.  The  ducts,  minute 
in  size  and  about  twelve  in  number,  open  in  the 
outer  part  of  the  conjunctival  reflection.  Excision 
of  the  gland  presents  no  technical  difficulty,  as  it 
is  loosely  bound  to  the  structures  in  its  neighbour- 
hood. It  may  inflame,  and  become  so  enlarged 
as  to  appear  as  a  tumour,  which  may  displace 
the  globe  downwards  and  inwards,  and  press 
forwards  the  oculo-palpebral  fold  of  conjunctiva. 
If  an  abscess  forms,  it  most  usually  breaks  through 
the  skin  of  the  upper  Hd.  Cystis  of  the  gland 
(dacryops)  are  due  to  obstruction  and  distension 
of  some  of  its  ducts.  The  normal  secretion  of  the 
gland  keeps  the  exposed  surface  of  the  eye  moist, 
yet  the  gland  may  be  excised  without  giving  rise 
to  any  untoward  effect. 

The  lacrimal  sac  is  situated  at  the  side  of  the 
nose,  near  the  inner  canthus  (medial  palpebral 
commissure),  and  lies  in  a  groove  on  the  lacrimal 
and  superior  maxillary  bones  (Fig.  21).  On  its 
outer  side,  and  a  little  anteriorly,  it  receives 
the  two  lacrimal  canaliculi.  In  front  of  the 
sac  is  the  internal  palpebral  ligament  or  tendo 
oculi.  If  the  two  lids  be  forcibly  drawn  out- 
wards this  ligament  can  be  readily  felt  and 
seen,  and  serves  as  a  guide  to  the  sac.  It  can 
also  be  felt  as  it  is  tightened  when  the  lids  are 
firmly  closed.  It  crosses  the  sac  at  right  angles, 
and  at  about  the  junction  of  its  upper  third  with 
its  lower  two-thirds.  A  knife  entered  immediately 
below  the  ligament  would  about  open  the  middle 
of  the  sac;  and  it  may  be  noted  that  a  lacrimal 
abscess,  when  about  to  discharge,  always  points 
below  the  ligament.  Epiphora,  or  overflow  of 
tears,  is  due  in  the  main  to  two  causes:  (1)  to 
an  obstruction  in  any  part  of  the  lacrimal  pas- 
sages, from  the  puncta  to  the  opening  of  the  nasal 
or  naso-lacrimal  duct  in  the  nose;  (2)  to  any  cause 


IV] 


THE   LACRIMAL  SAC 


85 


that  removes  the  lower  punctum  from  its  contact 
with  the  globe,  as  may  be  the  case  in  ectropion, 
in  entropion,  in  swelling  of  the  lower  lid,  etc. 
It  is  the  pretarsal  part — the  fibres  of  the  orbi- 
cularis  oculi  which  span  the  lids  near  their  free 
margin — that  keeps  the  eyelids  appressed  to  the 
eyeball.  These  fibres  end  behind  the  lacrimal  sac  on 
the  posterior  lacrimal  crest,  and  form  the  muscle 

LAC.      GLAND 

Pl-ICA   SEMILUN. 

CANALICULUS 
NASION 


Fig.  21.— Diagram  of  the  lacrimal  apparatus. 

The  arrow  points  to  the  first  molar  tooth,  showing  the  direction  of 
the  nasal  duct. 

at  one  time  known  as  the  tensor  tarsi  or  Homer's 
muscle  (Whitnall).  Facial  palsy  causes  epiphora, 
because,  the  orbicular  muscle  being  relaxed,  the 
punctum  falls  away  from  the  globe,  and.  more- 
over, the  passage  of  the  tears  is  no  longer  aided 
by  the  suction  action  effected  by  the  muscle  in  the 
process  of  winking.  The  canaliculi  may  readily  be 
slit  up  with  a  proper  knife,  and  a  probe  can 
without  difficulty  be  passed  down  the  nasal  duct 
from  the  lacrimal  sac. 


86  THE    HEAD    AND    NECK 

The  nasal  duct  (naso-lacrimal)  is  a  little 
over  £  an  inch  in  length,  and  the  probe  that 
traverses  it  should  pass  downwards,  and  a  little 
backwards  and  outwards,  in  the  direction  of  the 
first  molar  tooth  (Fig.  21).  The  nasal  duct  per- 
forates the  mucous  membrane  of  the  nose  below 
the  inferior  turbinate  process  very  obliquely,  so 
that  its  inner  wall  acts  as  a  valve.  If  this  is 
destroyed  by  ulceration,  as  sometimes  occurs  in 
syphilis,  the  lacrimal  sac  may  be  inflated  by 
blowing  the  nose.  The  bony  nasal  duct  has  a 
calibre  which  varies  from  2'5  to  7'5  mm.  in  dia- 
meter ;  the  thick  mucous  membrane  which  lines 
it  has  a  rich  venous  plexus  in  its  submucous  layer 
which  readily  swells  and  prevents  the  passage  of 
tears  when  the  duct  is  inflamed.  The  normal  duct 
will  take  a  probe  measuring  3'5  mm.  in  diameter ; 
it  must  be  remembered  that  the  lumen  of  the  duct 
is  normally  closed,  and  that  its  lining  membrane 
possesses  several  transverse  folds  which  may  catch 
the  point  of  a  probe.  Inflammatory  conditions 
readily  ascend  from  the  nasal  cavity  to  the  lacri- 
mal sac  through  the  nasal  duct. 

As  affections  of  the  lacrimal  sac  are  often  very 
painful,  it  may  be  noted  that  the  nerve  supply  of 
the  sac  is  derived  from  the  infratrochlear  branch 
of  the  nasal  nerve. 


CHAPTER    V 
THE   EAR 

The  pi  1111:1.  The  pinna  may  be  congenital ly 
absent,  or  there  may  be  accessory  auricles  situated 
upon  the  cheek  or  side  of  the  neck.  In  the  latter 
situation  the  so-called  accessory  or  supernumerary 
auricle  consists  of  an  irregular  leaf  of  fibro- 
cartilage  developed  from  the  margins  of  one  of 
the  lower  branchial  clefts  (see  p.  209).  The  tag- 
like  supernumerary  auricles  that  are  found  on 
the  cheek  just  in  front  of  the  pinna  or  meatus 
are  due  to  the  irregular  development  or  want  of 
fusion  of  one  or  more  of  the  six  tubercles  from 
which  the  pinna  itself  is  developed.  The  pinna 
may  present  a  congenital  fistula  dependent  on  a 
defective  closure  of  the  first  branchial  cleft.  The 
position  of  this  cleft  is  represented  in  the  normal 
ear  by  the  Eustachian  tube,  the  tympanum,  and 
the  external  auditory  meatus,  the  pinna  being 
developed  from  the  integument  bordering  the  cleft. 
Some  of  the  smaller  and  more  superficial  fistulse  are 
due  not  to  a  defective  closure  of  the  branchial  cleft 
but  to  want  of  complete  fusion  between  certain  of 
the  tubercles  from  which  the  pinna  is  primarily 
developed.  Accidental  removal  of  the  pinna  is 
usually  associated  with  but  comparatively  little 
diminution  in  the  acuteness  of  hearing. 

The  skin  covering  the  auricle  is  thin  and  closely 
adherent.  The  subcutaneous  tissue  is  scanty,  and 
contains  but  very  little  fat.  In  inflammatory  con- 
ditions of  the  surface,  such  as  erysipelas,  the 
pinna  may  become  extremely  swollen  and  very 
great  pain  be  produced  from  the  tenseness  of  the 
parts.  The  pinna  and  cartilaginous  meatus  are 
87 


88  THE    HEAD    AND    NECK  [CHAP. 

very  firmly  attached  to  the  skull,  so  that  the  body, 
if  not  of  great  weight,  may  be  lifted  from  the 
ground  by  the  ears;  but  the  experiment  is  cruel 
and  dangerous. 

The  external  auditory  meatiis  is  about 
1|  inches  long.  It  is  important  to  remember  that 
the  meatus  is  directed  forwards  as  well  as  inwards  ; 
to  reach  and  expose  the  middle  ear  the  surgeon 
takes  the  posterior  wall  of  the  meatus  as  a  guide. 
The  external  meatus,  the  promontory,  the  cochlea, 
and  the  internal  meatus  lie  nearly  in  the  same  line. 
The  canal  has  a  vertical  curve  about  its  middle, 
with  the  convexity  upwards.  To  straighten  the 
canal  for  the  introduction  of  specula  and  other  in- 
struments, the  pinna  should  be  drawn  upwards  and 
a  little  outwards  and  backwards.  The  osseous  part 
forms  a  little  more  than  one-half  of  the  tube,  and  is 
narrower  than  the  cartilaginous  part. 

In  the  infant  at  1  year,  a  third  only  of  the 
meatus  is  formed  of  bone;  the  rest  is  car- 
tilaginous. In  a  child  5  or  6  years  of  age  the 
bony  and  cartilaginous  portions  of  the  meatus 
are  about  of  the  same  length  (Symington).  The 
narrowest  portion  of  the  meatus  _  is  about  its 
middle.  The  outer  orifice  is  elliptical,  with  its 
greatest  diameter  directed  from  above  downwards ; 
therefore  specula  should  be  elliptical  in  shape 
rather  than  round.  The  inner  end  of  the  tube,  on 
the  other  hand,  is  slightly  wider  in  the  transverse 
direction.  Owing  to  the  obliquity  of  the  mem- 
brana  tympani,  the  floor  of  the  meatus  is  longer 
than  the  roof.  The  cartilaginous  segment  of  the 
tube  presents  many  sebaceous  glands  that  may  be 
the  seat  of  minute  and  very  painful  abscesses.  ^  It 
also  presents  numerous  ceruminous  glands,  which 
secrete  the  cerumen  of  the  ear,  and  which,  when 
their  secretion  is  excessive,  may  produce  the  plugs 
of  wax  that  often  block  the  meatus  and  cause  deaf- 
ness. In  the  cartilage  of  the  floor  of  the  meatus 
are  certain  fissures,  fissures  of  Santorini.  They  are 
filled  up  with  fibrous  tissue.  They  permit  of  easier 
movement  of  the  cartilaginous  meatus.  It  is 


v]  EXTERNAL  AUDITORY   MEATUS  89 

through  these  gaps  in  the  cartilage  that  a  parotid 
abscess  may  burst  into  the  meatus.  There  are 
neither  hairs  nor  glands  in  the  lining  of  the  bony 
part  of  the  tube. 

The  skin  of  the  meatus,  when  inflamed,  may  pro- 
duce an  extensive  muco-purulent  discharge,  otitis 
externa.  Polypi  are  apt  to  grow  from  the  soft 
parts  of  the  canal,  and  exostoses  from  its  bony 
wall.  Foreign  bodies  are  frequently  lodged  in 
the  meatus,  and  are  often  very  difficult  to 
extract.  It  would  appear  that  in  many  cases 
more  damage  is  done  by  the  surgeon  than  by  the 
intruding  substance.  Mason  reports  three  cases 
where  a  piece  of  slate-pencil,  a  cherry-stone,  and  a 
piece  of  cedar-wood  were  lodged  in  the  canal  for 
respectively  40,  60,  and  30  years. 

The  upper  wall  of  the  meatus  is  in  relation  with 
the  cranial  cavity,  from  which  it  is  only  separated 
by  a  dense  layer  of  bone.  Thus,  abscess  or  bone  dis- 
ease in  this  part  may  possibly  lead  to  meningitis. 
A  case  is  reported  where  an  inflammation  of  the 
cerebral  membrane  followed  upon  the  retention 
of  a  bean  within  the  meatus.  The  anterior  wall 
of  the  canal  is  in  relation  with  the  temporo- 
maxillary  joint  and  with  part  of  the  parotid 
gland.  This  may  serve  in  one  way  to  explain  the 
pain  often  felt  in  moving  the  jaw  when  the 
meatus  is  inflamed,  although,  at  the  same  time,  it 
must  be  remembered  that  movement  of  the  lower 
maxilla  produces  a  movement  in  the  cartilagin- 
ous meatus,  and  that  both  the  canal  and  the  joint 
are  supplied  by  the  same  nerve  (the  auriculo- 
temporal).  From  its  relation  to  the  condyle  of 
the  jaw,  it  follows  that  this  wall  of  the  meatus 
may  be  fractured  in  falls  upon  the  chin.  Tillaux 
states  that  abscess  in  the  parotid  gland  may 
spread  into  the  meatus  through  the  anterior  wall 
of  the  passage.  The  posterior  wall  separates  the 
meatus  from  the  mastoid  cells.  Directly  behind 
the  posterior  wall,  at  a  distance  of  12  or  15  mm., 
is  the  lateral  sinus  (Fig.  24).  The  inferior 
wall  of  the  bony  meatus  is  very  dense  and  sub- 


90  THE    HEAD    AND    NECK  [CHAT. 

stantial,  and  corresponds  to  the  vaginal  and 
styloid  processes. 

Blooct  supply.  —  The  pinna  and  external 
meatus  are  well  supplied  with  blood  by  the  tem- 
poral and  posterior  auricular  arteries,  the  meatus 
receiving  also  a  branch  from  the  internal  maxillary. 
In  spite  of  this  supply,  the  pinna  is  frequently  the 
seat  of  gangrene  from  frost-bite.  This^  is  due  to 
the  fact  that  all  the  vessels  are  superficial  and  lie 
close  beneath  the  surface,  that  the  part  is  much 
exposed  to  cold,  and  that  the  pinna  lacks  the  pro- 
tection of  a  covering  of  fat.  The  same  conditions 
predispose  to  gangrene  of  the  nose  from  external 
cold.  Bloody  tumours  (hsematomata)  are  often  met 
with  on  the  pinna,  and  are  common  in  boxers, 
football  players,  and  lunatics.  They  are  due  to 
injury,  and  consist  of  an  extravasation  between 
the  perichondrium  and  the  cartilage. 

TVerye  supply. — The  pinna  is  supplied  by 
the  auriculo-temporal,  great  auricular,  and  small 
occipital  nerves  (see  Fig.  2,  p.  11).  The  meatus 
is  supplied  mainly  by  the  auriculo-temporal, 
with,  in  addition,  a  contribution  from  the  auri- 
cular branch  of  the  vagus  (Arnold's  nerve), 
which  goes  to  the  lower  and  back  part  of  the 
canal,  not  far  from  its  commencement.  A  sen- 
sory branch  from  the  facial  also  ends  in  the 
meatus  (Ramsay  Hunt).  The  auricular  branch 
of  the  vagus  has  been  credited  with  a  good  deal 
in  connexion  with  the  nerve  relations  of  the  ear. 
After  a  heavy  dinner,  when  the  rose-water  comes 
round,  it  is  common  to  see  the  more  experienced 
of  the  diners  touch  the  lower  part  of  the  back  of 
the  ear  with  the  moistened  serviette.  This  is  said 
to  be  very  refreshing,  and  is  supposed  to  be  an 
unconscious  stimulation  of  Arnold's  nerve,  a  nerve 
whose  main  trunk  goes  to  the  stomach.  Hence, 
this  little  branch  has  been  facetiously  termed 
"the  alderman's  nerve." 

Ear  coughing:,  ear  sneezing,  ear  yawning.— 
It  is  not  uncommon  to  have  a  troublesome  dry 
cough  associated  with  some  mischief  in  ihe 


v]  THE   EAR  91 

meatus.  Sometimes  the  mere  introduction  of  a 
speculum  will  make  the  patient  cough.  A  case 
is  reported  in  which  a  troublesome  cough  persisted 
for  eighteen  months,  and  at  once  ceased  on  the  re- 
moval of  a  plug  of  wax  from  the  ear.  In  such  cases 
the  irritation  is  conveyed  to  the  respiratory  and 
cough  centres  in  the  floor  of  the  fourth  ventricle 
by  the  auricular  branch  of  the  vagus.  Gaskell 
has  shown  that  the  vagus  also  contains  the  dis- 
associated visceral  fibres  of  the  fifth  nerve.  Hence, 
disturbances  may  be  set  up  in  the  vagal  nuclei 
through  branches  of  the  fifth  nerve,  such  as  the 
auriculo-temporal.  The  connexion  of  the  nerves 
of  the  external  auditory  meatus  with  the  vagal 
nuclei  explains,  too,  the  sneezing  or  vomiting  which 
is  sometimes  caused  by  the  presence  of  foreign 
bodies  in  the  external  meatus.  The  same  nerve- 
connexion  also  explains  the  occurrence  of  repeated 
yawning,  sometimes  set  up  by  ear  ailments.  Irrita- 
tion conveyed  along  the  inferior  dental  or  lingual 
nerves  may  be  referred  along  the  auriculo-tem- 
poral. Hence  the  need  to  examine  the  tongue  and 
lower  teeth  in  cases  of  earache.  Head  has  pointed 
out  that  disease  of  the  ear,  the  tonsil,  ^the  tongue, 
or  the  lower  jaw  may  be  associated  with  an  area 
of  tenderness  in  the  skin  along  and  below  the  jaw. 

It  is  a  common  practice  to  introduce  ear-rings 
with  the  idea  of  relieving  obstinate  affections  of 
the  ^  eye.  The  lobule  is  supplied  by  the  great 
auricular  nerve  which  springs  from  the  second 
and  third  cervical  nerves,  while  the  eye  is  supplied 
by  the  ophthalmic  division  of  the  fifth.  The  centres 
with  which  these  nerves  are  connected  have  a  defi- 
nite connexion,  for  the  lower  sensory  nucleus  of 
the  fifth  is  a  direct  continuation  upwards  of  the 
grey  matter  from  which  the  posterior  roots  of 
the  cervical  nerves  arise. 

Hilton  reports  a  case  of  obscure  pain  in  the  ear 
which  was  found  to  be  due  to  an  enlarged  gland 
in  the  neck  that  pressed  upon  the  trunk  of  the 
great  auricular  nerve. 

M  <  ml»r:i  11:1  ly  m  JKIIU. — This  membrane  is  very 


92 


THE    HEAD    AND    NEGK 


[CHAP. 


placed,  forming  with  the  horizontal  an 
angle  of  45°.  At  birth  it  appears  to  be  more  nearly 
horizontal,  although  it  is  not  really  so.  Owing  to 
the  sloping  downwards  of  the  bony  wall  of  the 
meatus  at  its  inner  end,  that  wall  forms  with  the 
lower  edge  of  the  membrane  a  kind  of  sinus  in 


Fig.  22.—  Section  through  the  external  meatus,  middle  ear, 
and  Eustachian  tube.     (Tillaux.} 

a,  External  auditory  meatus  ;  b,  attic  of  tympanum  ;  c,  Eust 
tube  ;  d,  internal  auditory  meatus  ;  e,  cochlea  ;/,  ossicles  ;  (/, 
brana  tympani  :  h,  styloid  process. 


Eustachian 
mem- 


which  small  foreign  bodies  may  readily  lodge 
(Fig.  22).  The  ring  of  bone  to  which  the  membrane 
is  attached  is  deficient  at  its  upper  and  anterior 
part.  The  gap  so  formed  is  called  the  tympanic 
notch  or  notch  of  Rivini,  and  is  occupied  by  loose 
connective  tissue,  covered  by  a  continuation  of  the 


v]  MEMBRANA   TYMPANI  93 

lining  of  the  meatus,  and  through  it  pus  may 
escape  from  the  middle  ear  into  the  auditory  canal 
without  perforating  the  membrane.  When  the 
membrane  gives  way  owing  to  a  violent  concussion 
transmitted  through  the  air,  it  often  gives  way 
opposite  the  notch,  its  attachments  here  being  ob- 
viously less  secure  than  elsewhere.  The  membrane 
possesses  but  little  elasticity,  as  shown  by  the  very 
slight  gaping  of  the  part  after  it  has  been  wounded. 
It  is  for  this  reason,  among  others,  that  perfora- 
tions made  in  the  membrane  by  the  surgeon  heal 
so  very  rapidly.  The  membrane  has  been  ruptured 
during  fits  of  sneezing,  coughing,  vomiting,  etc. 
The  same  lesion  has  followed  a  box  on  the  ear,  and 
even  simple  concussions  such  as  that  produced  by 
a  loud  report. 

The  umbo,  or  deepest  point  of  the  depression, 
is  just  below  the  centre  of  the  entire  membrane, 
and  corresponds  to  the  attachment  of  the  end 
of  the  handle  of  the  malleus.  The  rest  of  the 
handle  can  be  seen  through  the  membrane  dur- 
ing life.  The  head  of  the  malleus  is  in  no  con- 
nexion with  the  membrane,  being  situated  in  the 
attic  of  the  tympanum  above  the  level  of  the  mem- 
brane (Fig.  22).  The  segment  of  the  membrane 
above  the  umbo  is  very  freely  supplied  by  vessels 
and  nerves  ;  it  corresponds  to  the  handle  of  the 
malleus,  and  to  the  chain  of  ossicles,  and  is 
opposite  to  the  promontory  and  the  two  fenestrse. 
The  chorda  tympani  nerve  also  runs  across  this 
supraumbilical  portion.  The  segment  below  the 
umbo,  on  the  other  hand,  corresponds  to  no  very 
important  parts,  and  is  less  vascular  and  less  sen- 
sitive. Paracentesis  of  the  tympanum  through  the 
membrana  tympani  should  therefore  always  be 
performed  in  the  subumbilical  segment.  If  per- 
formed above  the  umbo  the  knife  may  strike  the 
incus  and  loosen  that  bone  from  its  attachments, 
or  the  chorda  tympani  may  be  cut,  which  would 
give  rise  to  a  paralytic  secretion  of  saliva.  The 
malleus  and  stapes  are  too  firmly  attached  to  be 
readily  detached. 


94 


THE    HEAD    AND    NECK 


[CHAP. 


The  membrane  is  supplied  by  the  stylo-mastoid 
artery  and  the  tympanic  branch  of  the  internal 
maxillary,  and  obtains  its  nerve  supply  from  the 
auriculo-temporal,  facial,  and  vagus. 

The  tympanum.—  The  width  of  the  tympanic 
cavity,  as  measured  from  its  inner  to  its  outer 
wall,  varies  from  2  to  4  mm.,  TV  to  |  of  an  inch. 
The  narrowest  part  is  that  between  the  umbo  of 
the  membrana  and  the  promontory.  A  fine  rod 


A/NTCUM 
,EXT.5EMICIRC.CA/HAL 


ADITUS 

FENESTRA  OVALIS 
TECMEM      TVMPANI 
PROCES5U5  COCM. 


Fig.  23. — Inner  wall  of  tympanum  and  antrum. 

The  position  of  the  external  semicircular  canal  and  course  of  the 
facial  nerve  (vii.)  are  shown. 

thrust  through  the  centre  of  the  membrana  tympani 
would  hit  the  promontory  of  the  inner  wall  of 
the  cavity.  Above  the  promontory  is  the  fencstra 
pvalis  (fenestra  vestibuli),  and  below  and  behind 
it  the  fenestra  rotunda  (fenestra  cochleae)  (Fig.  23). 
Skirting  the  upper  and  posterior  margin  of  the 
inner  wall  of  the  tympanum  is  the  facial  canal 
or  aqueduct  of  Fallopius,  containing  the  facial 
nerve.  The  wall  of  the  aqueduct  is  so  thin  that 
inflammatory  mischief  can  readily  extend  from 
the  middle  ear  to  the  facial  nerve.  The  upper 


v]  TYMPANIC   SINUS  95 

wall  or  roof  is  very  thin,  and  but  little  bone 
separates  it  from  the  cranial  cavity.  The  suture 
between  the  squamous  and  petrous  bones  is  found 
in  this  wall,  and  by  means  of  the  sutural  mem- 
brane which  separates  the  bones  in  the  young, 
inflammatory  changes  may  readily  spread  from  the 
tympanum  to  the  meninges.  The  petro-squamous 
suture  unites  at  the  end  of  the  first  year  and  usually 
contains  the  petro-squamous  vein,  a  remnant  of 
the  primitive  jugular.  The  floor  is  very  narrow.  Its 
lowest  part  is  below  the  level  of  both  the  mem- 
brana  tympani  and  the  orifice  of  the  Eustachian 
tube,  and  hence  pus  may  readily  collect  in  this 
locality  (Fig.  23).  It  is  separated  by  a  thin  piece 
of  bone  from  the  internal  jugular  vein  behind,  and 
from  the  internal  carotid  artery  in  front.  Fatal 
haemorrhage  from  the  latter  vessel  has  occurred  in 
connexion  with  destructive  changes  in  this  part 
of  the  ear.  The  posterior  wall  in  its  upper  part 
presents  the  opening  or  aditus  of  the  tympanic 
sinus  (antrum  of  the  mastoid).  This  air  sinus 
opens  into  the  attic — that  part  of  the  tympanic 
cavity  which  is  situated  above  the  level  of  the 
membrana  tympani  (Fig.  24). 

The  tympanic  sinus  (aiitrum  of*  the  mas- 
toid) (Figs.  22  and  24)  lies  above  and  behind  the 
external  auditory  meatus.  Implication  of  this 
space  and  of  the  mastoidal  cells,  which  open 
into  it  and  surround  it,  forms  one  of  the  most 
serious  complications  of  middle-ear  disease.  It 
is  large  enough  to  contain  a  small  bean,  and 
is  present  at  birth  (Fig.  25),  being  developed 
with  the  cavity  of  the  tympanum.  It  is  closely 
surrounded  by  important  structures.  Its  roof, 
formed  by  the  tegmen  tympani,  a  plate  of  bone 
only  2  mm.  thick,  separates  it  from  the  third 
temporal  convolution.  Small  veins  perforate  the 
roof  to  join  the  petro-squamous  vein,  in  the  rem- 
nant of  the  suture  of  the  same  name.  In  the  infant 
the  communication  is  even  more  free,  for  this 
suture  does  not  close  until  the  end  of  the  first  year. 
The  canal  for  the  facial  nerve  passes  downwards 


96 


THE    HEAD    AND    NECK 


[CHAP. 


on  its  inner  wall,  where  the  antrum  opens  into 
the  attic,  and  behind  the  facial  nerve,  also  on 
the  inner  wall,  is  the  external  semicircular  canal 
(Fig.  23).  Facial  paralysis  or  giddiness  may 
follow  operations  on  the  antrum  if  the  inner  wall 
is  injured.  The  superior  and  posterior  borders 
of  the  meatus  indicate  the  position  of  the  facial 
nerve  (Fig.  24);  on  the  inner  wall  of  the  sinus 
or  antrum  the  nerve  is  situated  14  to  22  mm.  deep 


FACIA 


r 

Fig.   24.  —  Showing    the    position   and  relationships  of   the 
various  parts  of  the  middle  ear.      (See  also  Fig.  4.  p.  15.) 

to  the  supramcatal  triangle  (Joyce).  The  sinus 
is  separated  from  the  lateral  sinus  and  cerebellum 
behind  by  a  plate  of  bone  which  varies  in  thick- 
ness from  3  mm.  to  6  mm.  It  can  thus  be  readily 
understood  why  the  temporo-sphenoidal  lobe,  the 
lateral  sinus,  and  the  cerebellum  should  be  the 
common  seats  of  secondary  infection  in  cases  of 
middle-ear  disease.  At  the  mouth  of  the  tympanic 
sinus  and  in  the  attic  of  the  tympanum  are 
situated  the  incus,  the  head  of  the  malleus,  and 
their  ligaments,  structures  which  may  be  diseased 
and  require  removal. 


v]  TYMPANIC   SINUS  97 

At  birth  the  outer  wall  of  the  sinus  is  formed 
by  the  postmeatal  process  of  the  squamosal,  a  plate 
of  bone  2  mm.  thick  (Fig.  25).  In  the  child  the 
antrum  is  comparatively  superficial,  and  pus  may 
easily  escape  or  be  evacuated.  The  suture  between 
the  postmeatal  part  of  the  squamosal  and  the 
petro-mastoid  disappears  in  the  second  year  of  life, 
and  so  shuts  off  a  possible  route  that  pus  may  take 
to  reach  the  surface  (Fig.  25).  The  outer  wall 
of  the  sinus  steadily  increases  in  thickness  until 


SQUAMOSAL 


POST.  I/NF  FowTA«ELLEx^?!flV^4DB.AAiT.  IMF   FOMTANELLE 


5QUANO  /IASTO 
SUTURE 

^TYMPANIC  RlrtQ 

DRUM 

'ST/LO-AIASTOID  FORAMEM 
Fig.  25. — Temporal  bone  at  birth. 

The  positions  of  the  tympanic  sinus  or  antrum  and  attic  are 
indicated.  The  squamo-mastoid  suture  is  open  and  the 
mastoid  process  undeveloped. 

adult  life,  when  the  depth  of  the  cavity  from  the 
surface  of  the  bone  is  found  to  vary  in  different  in- 
dividuals from  12  to  22  mm.,  about  16  mm.  being 
its  average  depth.  A  shallow  triangle  (see  Fig.  24) 
above  and  behind  the  meatus  lies  directly  over  the 
antrum  and  serves  as  a  guide  to  its  position.  It 
may  also  IDC  reached  by  following  the  junction  of 
the  posterior  wall  and  roof  of  the  external  auditory 
meatus.  The  drill  is  entered  5  mm.  behind  the 
meatus  and  on  a  level  with  its  upper  margin.  Its 
roof  lies  5  mm.  above  the  level  of  the  meatus.  The 
E 


98  THE    HEAD    AND    NECK  [CHAP. 

posterior  auricular  artery  passes  upwards  behind 
the  meatus,  beneath  the  concha  of  the  auricle,  and 
lies  within  the  field  of  any  operation  on  the  middle 
ear. 

The  mastoid  cells  develop  with  the  growth  of 
the  mastoid  process,  which  appears  as  a  definitely 
marked  structure  in  the  second  year.  Besides  the 
sinus  there  are  also  some  cells  present  in  the 
outer  wall  at  birth  (Young).  During  infancy 
there  are  two  types  of  mastoid  :  one  in  which 
the  bone  is  dense — a  form  that  persists  in  1  per 
cent,  of  adults;  and  one  in  which  the  mastoid  is 
diploetic— a  form  that  is  retained  in  20  per  cent, 
of  adults  (A.  Cheatle).  Three  varieties  of  the 
mastoid  process  are  recognized  in  adults,  each 
of  which  is  about  equally  common:  (1)  those 
in  which  the  cells  are  large  and  communicate 
with  each  other  and  with  the  tympanic  sinus; 
(2)  those  in  which  the  central  cells  are  large  and 
communicate  with  the  sinus,  while  the  peripheral 
are  small  and  closed;  (3)  those  in  which  all  the 
spaces  are  small  and  closed.  The  cells  surround 
the  sinus,  and  may  pass  backwards  to  the  masto- 
occipital  suture,  forwards  to  the  suprameatal 
region,  upwards  to  the  masto-parietal  suture,  and 
downwards  to  the  apex  of  the  mastoid.  Inflamma- 
tory conditions  may  lead  to  a  thickening  of  the 
walls  of  the  mastoidal  cells,  and  the  bone  may  be- 
come so  dense  as  almost  to  resist  the  chisel.  Veins 
drain  into  the  periosteal  veins  of  the  mastoid 
from  the  more  superficial  cells*  and  by  these  in- 
flammation may  reach  the  surface  and  give  rise 
to  oedema  and  swelling  behind  the  ear. 

In  cases  where  the  outer  surface  of  the  mastoid 
has  been  spontaneously  perforated,  a  tumour, 
containing  air,  has  appeared  on  the  skull,  and 
it  has  been  observed  that  the  tumour  may 
be  increased  in  size  by  forcing  air  into  the  ear 
through  the  Eustachian  tube.  Such  tumours  are 
known  as  pneumatoceles,  and  ^the  process  that 
leads  originally  to  the  perforation  of  the  bone  is 
of  obscure  nature.  In  some  cases  it  seems  to  have 


vj  EUSTACHIAN   TUBE  99 

been  simply  atrophic,  and  in  other  instances  to 
have  been  due  to  "  caries  sicca." 

On  the  anterior  wall  of  the  tympanum  is  the 
opening  of  the  Eii*tarlii:tii  tube  (Figs.  22  and  23). 
This  tube,  If  inches  long,  by  opening  into  the 
pharynx  serves  to  keep  a  proper  supply  of  air  in 
the  tympanum,  and  so  equalize  the  pressure  upon 
the  two  sides  of  the  membrane.  The  floor  of  the 
tympanum  is  below  the  level  of  the  outer  opening  of 
the  Eustachian  tube.  The  line  of  direction  of  the 
tube  lies  almost  exactly  midway  between  the  trans- 
verse and  antero-posterior  axes  of  the  base  of  the 
skull.  In  the  adult  it  inclines  downwards,  so  as  to 
form  an  angle  of  40°  with  the  horizontal.  In  the 
child  this  angle  is  only  10°  (Symington).  In  adults 
three-fourths  of  the  tube  is  cartilaginous  and  one- 
fourth  bony  (Symington).  On  the  outer  side  lie  the 
tensor  palati,  the  third  division  of  the  fifth  nerve, 
and  the  middle  meningeal  artery;  on  the  inner 
side,  the  retropharyngeal  tissue  and  (quite  pos- 
teriorly) the  internal  carotid  artery.  The  pharyn- 
geal  orifice  of  the  tube  is  usually  shut.  During 
swallowing,  however,  it  is  opened  by  the  action 
mainly  of  the  tensor  palati  muscle.  If  the  nose  and 
mouth  be  closed  and  the  cheeks  blown  out,  a  sense 
of  pressure  is  produced  in  both  ears.  The  hearing, 
at  the  same  time,  is  dulled,  and  the  change  is  due 
to  the  bulging  out  of  the  membrana  tympani  by  the 
air  thus  forced  into  the  tympanum.  This  method 
of  inflating  the  middle  ear  is  known  as  VaKsalva's 
method. 

In  Politzer's  method  of  passing  air  into  the 
Eustachian  tube,  the  patient's  mouth  is  closed, 
while  into  one  nostril  the  nozzle  of  a  caoutchouc 
bag  filled  with  air  is  introduced,  and  the  nostrils 
are  then  held  firmly  closed.  The  patient  is  asked  to 
swallow  a  mouthful  of  water,  while  at  the  same 
moment  the  bag  is  forcibly  emptied,  and  the  air, 
having  no  other  means  of  escape,  is  thus  driven 
into  the  open  Eustachian  tube.  The  surgeon  listens 
for  the  little  noise  caused  by  the  entrance  of  the 
air  by  means  of  a  tube  that  passes  between  the 


100  THE    HEAD    AND    NEGK  [CHAP. 

patient's  meatus  and  his  own.  Prolonged  closure 
of  the  Eustachian  tube  leads  to  deafness,  and  thus 
impairment  of  hearing  may  follow  upon  great 
thickening  of  the  mucous  membrane  of  the  tube 
due  to  the  extension  of  inflammatory  mischief 
from  the  pharynx.  In  the  deafness  associated  with 
enlarged  tonsils  and  postnasal  growths  the  hyper- 
trophic  change  extends  to  the  mucous  lining  of 
the  tube,  and  in  many  pharyngeaJ  growths  and 
nasal  polypi  the  orifice  of  the  tube  is  mechanically 
obstructed.  The  near  relation  of  the  pharyngeal 
end  of  the  tube  to  the  posterior  nares  serves  to 
explain  a  case  where  suppuration  in  the  mastoid 
cells  followed  upon  plugging  of  the  nares  for 
epistaxis.  Infection  may  be  carried  up  to  the 
middle  ear  by  means  of  the  ciliated  lining  of  the 
Eustachian  tube ;  C.  J.  Bond  found  that  indigo 
particles,  which  had  been  blown  within  the  naso- 
pharynx, in  a  case  of  perforation  of  the  drum,  ap- 
peared afterwards  in  a  discharge  from  the  external 
meatus. 

The  upper  edge  of  the  pharyngeal  orifice  of  the 
tube  is  about  ^  an  inch  below  the  basilar  process, 
\  an  inch  in  front  of  the  posterior  wall  of  the 
pharynx,  \  an  inch  behind  the  posterior  end  of 
the  inferior  turbinate  bone,  and  ^  an  inch  above 
the  soft  palate  (Tillaux).  In  the  foetus  the  orifice 
is  below  the  hard  palate ;  at  birth,  on  the  same 
level.  The  form  of  the  opening  is  that  of  a 
triangle. 

Just  behind  the  elevation  formed  at  the  orifice 
of  the  Eustachian  tube  there  is  a  depression  in  the 
wall  of  the  pharynx,  the  pharyngeal  recess  or  fossa 
of  Rosenmuller  (Fig.  27,  p.  111).  It  may  be  mis- 
taken for  the  orifice  of  the  tube,  and  may  readily 
engage  the  point  of  a  Eustachian  catheter.  In 
cases  in  which  the  pharyngeal  tonsil  (Luschka's 
tonsil)  is  enlarged,  this  fossa  on  either  side  may 
bo  greatly  deepened  and  made  to  form  a  narrow 
diyerticulum.  (See  p.  167.)  To  pass  the  Eusta- 
chian catheter,  the  instrument  is  carried  along 
the  floor  of  the  nares  with  its  concavity  down- 


v]  VESSELS   OF  THE   TYMPANUM  101 

wards,  "until  its  point  can  be  felt  to  drop  over 
the  posterior  edge  of  the  hard  palate  into  the 
pharynx.  The  instrument  should  now  be  with- 
drawn until  its  point  can  be  felt  to  rise  again 
on  the  posterior  edge  of  the  hard  palate;  having 
arrived  at  this  point,  the  catheter  should  be 
pushed  onwards  about  1  inch,  and  during  its 
passage  its  point  should  be  rotated  outwards 
through  a  quarter  of  a  circle."  This  mano3uvre 
should  engage  it  on  the  orifice  of  the  tube. 

Blood  supply  of  the  tympanum. — The  arte- 
ries supplying  the  tympanum  are  the  tympanic  of 
the  internal  maxillary  and  internal  carotid,  the 
petrosal  of  the  middle  meningeal,  and  the  stylo- 
mastoid  of  the  posterior  auricular.  The  fact  that 
some  of  the  tympanic  veins  end  in  the  superior 
petrosal  and  lateral  sinuses  gives  another  ex- 
planation of  the  frequent  recurrence  of  thromboses 
of  those  channels  in  inflammatory  affections  of 
the  middle  ear.  The  petro-squamous  vein,  which 
crosses  the  roof  of  the  middle  ear,  also  receives 
branches  from  the  tympanic  sinus  and  attic,  and 
joins  the  lateral  sinus  behind  and  the  meningeal 
veins  in  front  (Cheatle). 

The  lymphatics  of  the  middle  ear  follow  two 
routes.  The  majority  pass  along  the  wall  of  the 
Eustachian  tube  and  end  in  the  retropharyngeal 
lymphatic  gland.  Others  reach  the  postauricular 
group  of  glands,  situated  over  the  mastoid  process, 
by  passing  out  beneath  the  lining  membrane  of 
the  meatus  and  by  other  efferent  channels  which 
accompany  the  veins  escaping  by  the  superficial 
openings  that  are  seen  on  the  mastoid  part  of 
the  temporal. 

The  chorda  tympani  nerve,  from  its  exposed 
position  in  the  tympanum,  is  very  likely  to  be 
damaged  in  suppurative  disease  of  the  middle 
ear ;  and  it  has  been  shown  that,  when  this  nerve 
is  involved,  there  may  be  a  disturbance  of  the 
sense  of  taste,  which  is  easily  understood  when 
one  remembers  that  some  of  the  nerves  of  taste 
reach  the  tongue  by  this  route. 


102  TflE    IIF,AB    AND 

The  osseous  labyrinth  is  formed  independ- 
ently of  the  other  bony  parts  of  the  ear.  Portions 
of  this  labyrinth  have  necrosed  and  have  been 
expelled  in  recognizable  fragments.  In  a  case 
recorded  by  Dr.  Barr  the  whole  of  the  osseous 
labyrinth  (the  cochlea,  vestibule,  and  semicircular 
canals)  was  removed  entire  as  a  necrosed  frag- 
ment from  the  auditory  meatus.  Suppuration 
of  the  middle  ear  may  spread  to  the  inner  ear 
by  invading  the  external  semicircular  canal — the 
most  common  route  (Scott  and  West) — and  eroding 
the  promontory;  by  the  fenestra  ovalis,  in  which 
the  footplate  of  the  stapes  is  fixed  by  the  strong 
annular  membrane;  or  by  the  fenestra  rotunda, 
which  is  closed  by  the  membrana  secundaria. 
When  inflammatory  infections  spread  to  the  inner 
ear,  two  series  of  symptoms  result:  (1)  disturb- 
ances of  hearing  and  deafness  following  the  spread 
of  inflammation  and  suppuration  to  the  cochlea, 
through  the  perilymph  system  (scala  vestibuli  and 
scala  tympani) ;  (2)  disturbances  of  balancing  and 
co-ordination — vertigo  and  vomiting — from  injury 
and  destruction  of  the  saccule,  utricle,  and  am- 
pullae of  the  semicircular  canals.  The  perilymph 
system  of  the  inner  ear  gives  only  too  easy  a 
means  for  the  spread  of  inflammation.  From 
the  inner  ear  the  suppurative  process  may  extend 
inwards  along  the  auditory  nerve  and  meatus, 
thus  reaching  the  large  subarachnoid  spaces  at 
the  base  of  the  brain.  It  may  also  reach  the 
cranial  contents  by  the  aqueductus  vestibuli  or 
aqueductus  cochlea,  or  by  a  perforation  of  the 
superior  semicircular  canal.  Middle-ear  disease 
may  lead  to  the  formation  of  a  fistulous  opening 
in  the  external  semicircular  canal.  In  such  cases 
movements  of  the  head  may  give  rise  to  nystagmus, 
for  reflex  movements  of  the  eyes  are  influenced 
by  stimuli  which  arise  in  the  maculae  of  the  semi- 
circular canals  (Sydney  Scott). 


CHAPTER   VI 
THE    NOSE    AND    NASAL    CAVITIES 

THE  NOSE 

THE  skin  over  the  root,  and  the  greater  part 
of  the  dorsum,  of  the  nose  is  thin  and  lax. 
Over  the  alse,  however,  it  is  thick,  very  adherent 
to  the  deeper  parts,  and  plentifully  supplied 
\vith  sebaceous  and  sweat-glands.  Inflamma- 
tion of  the  integuments  over  the  cartilaginous 
portion  of  the  nose  is  apt  to  be  very  painful, 
and  to  be  associated  with  much  vascular  engorge- 
ment. The  pain  depends  upon  the  tenseness  of  the 
part,  which  prevents  it  from  swelling  without  pro- 
ducing much  pressure  upon  the  nerves,  while  the 
engorgement  depends  upon  the  free  blood  supply 
of  the  region,  and  the  fact  that,  the  edge  of  the 
nostril  being  a  free  border,  the  circulation  there 
is  terminal,  and  apt  therefore  to  favour  con- 
gestion. 

The  great  number  of  sebaceous  glands  about 
the  lower  part  of  the  nose  renders  it  a  favourite 
spot  for  acne.  It  is  here  that  the  form  of  acne 
termed  acne  hypertrophica  is  met  with — a  con- 
dition that  produces  the  appearance  known  as 
"  grog  blossoms/'  The  nose,  too,  is  frequently 
attacked  by  lupus,  and  it  is  over  the  dorsum 
of  the  nose  that  lupus  erythematosus  is^  most 
commonly  met  with.  Rodent  ulcer  also  is  apt 
to  appear  in  this  region,  especially  in  the  fold 
between  the  ala  of  the  nose  and  the  cheek. 

The  integument  of  the  nose  is  very  well  sup- 
plied with  blood,  and  for  this  reason  the  part  is 
well  suited  for  the  many  plastic  operations  that 
103 


104  THE    HEAD    AND    NECK  [CHAP. 

are  performed  upon  it.  Wounds  in  this  region 
heal  kindly,  and  even  the  extensive  wound  made 
along  the  line  between  the  nose  and  the  cheek  in 
removal  of  the  upper  jaw  leaves  very  little  de- 
formity. In  many  reported  cases  portions  of  t the 
nose  have  been  entirely  severed,  and  have  united 
to  the  face  on  being  immediately  re-applied. 

The  skin  over  the  root  of  the  nose  is  supplied 
by  the  nasal  branch  of  the  first  division  of  the 
fifth;  as  is  also  the  skin  over  the  alse  and  in 
the  region  of  the  nostril  (Fig.  2,  p.  11).  The 
greater  part  of  the  side  of  the  nose  is  supplied  by 
the  second  division  of  the  fifth,  and  is  the  seat  of 
pain  in  neuralgia  of  that  trunk.  The  fact  that 
the  nasal  nerve  is  a  branch  of  the  ophthalmic 
trunk,  and  has  intimate  connexions  with  the  eye, 
serves  to  explain  the  lacrimation  that  often 
follows  painful  affections  about  the  nostril,  as, 
for  example,  when  the  edge  of  the  nostril  is 
pinched. 

The  cartilaginous  part  of  the  nose  is  often 
destroyed  by  lupus,  by  syphilitic  ulceration,  and 
other  destructive  affections.  The  parts  so  lost 
have  been  replaced  by  the  various  methods  in- 
cluded under  the  head  of  rhinoplasty.  It  is  well 
to  bear  in  mind  the  limits  of  the  cartilaginous 
segment  of  the  nose,  and  to  remember  that  in  in- 
troducing a  dilating  speculum  the  instrument 
should  not  be  passed  beyond  ^hose  limits.  In  the 
subjects  of  inherited  syphilis  the  bridge  of  the 
nose  is  often  found  to  be  greatly  depressed.  This 
depends  upon  no  actual  loss  of  parts,  but  rather 
upon  ^ imperfect  development  from  local  mal- 
nutrition, that  malnutrition  following  upon  a 
severe  catarrh  of  the  mucous  membrane.  The  de- 
formity only  occurs,  therefore,  in  those  who  have 
had  "  snuffles  "  in  infancy. 

The  nasal  bones  are  often  broken  by  direct 
violence.  The  fracture  is  most  common  through 
the  lower  third  of  the  bones,  where  they  are  thin- 
nest and  least  supported.  It  is  rarest  in  the 
upper  third,  where  the  bones  are  thick  and  firmly 


vi]  THE  NOSE  105 

held,  and  where,  indeed,  considerable  force  is 
required  to  produce  a  fracture.  Since  no  muscles 
act  upon  the  ossa  nasi,  any  displacement  that 
occurs  is  due  solely  to  the  direction  of  the  force. 
Union  takes  place  after  these  fractures  with 
greater  rapidity  than  perhaps  obtains  after  frac- 
ture of  any  other  bone  in  the  body.  In  one  case 
noted  by  Hamilton,  "  the  fragments  were  quite 
firmly  united  on  the  seventh  day."  If  the  mucous 
membrane  of  the  nose  be  torn,  these  fractures  are 
apt  to  be  associated  with  emphysema  of  the  sub- 
cutaneous tissue,  which  is  greatly  increased  on 
blowing  the  nose.  The  air  in  such  cases  is  de- 
rived, of  course,  from  the  nasal  fossae.  In  frac- 
tures of  the  upper  third  of  the  ossa  nasi  the 
cribriform  plate  may  be  broken,  but  it  is  ques- 
tionable whether  this  complication  can  occur 
when  the  fracture  is  limited  to  the  lower  third 
of  the  bones.  The  root  of  the  nose  is  a  favourite 
place  for  meningoceles  and  encephaloceles,  the 
protrusion  escaping  through  the  suture  between 
the  nasal  and  frontal  bones.  Such  protrusions, 
when  occurring  in  this  place,  are  often  covered 
with  a  thin  and  vascular  integument,  and  have 
been  mistaken  for  nsevoid  growths. 

THE  NASAL  CAVITIES 

The  anterior  narcs  have  somewhat  the 
shape  of  the  heart  on  a  playing-card,  and  the 
aperture  as  a  whole  measures  about  li  inches 
vertically,  and  a  little  less  than  l\  inches  trans- 
versely, at  its  widest  part.  The  plane  of  the 
nostril  is  a  little  below  that  of  the  floor  of 
the  nares.  To  examine  the  nasal  cavities,  there- 
fore, the  head  should  be  thrown  back  and  the 
nose  drawn  upwards.  The  anterior  nares  can  be 
well  explored  by  the  finger  introduced  into  the 
nostril,  and  the  nasal  apertures  are  just  so  wide 
on  each  side  of  the  septum  as  to  allow  the  finger 
to  be  passed  far  enough  back  to  reach  another 
finger  introduced  into  the  posterior  nares  through 
the  mouth.  An  effectual  way  of  removing  soft 


106  THE    HEAD    AND    NECK  [CHAP. 

polypi  in  the  adult  is  by  tearing  them  away  by 
two  fingers  so  introduced.  The  operation  is  a 
little  rough.  By  the  most  gentle  introduction  of 
the  finger  into  the  nostril  it  is  often  possible  to 
feel  the  end  of  the  inferior  turbinated  bone.  ^  The 
anterior  nares,  and  front  of  the  nasal  cavities, 
can  be  well  explored  by  Rouge's  operation.  In 
this  procedure  the  upper  lip  is  everted,  and  a 
transverse  cut  made  through  the  mucous  mem- 
brane into  the  soft  parts  that  connect  the  upper 
lip  with  the  upper  jaw.  The  incision  extends  be- 
tween the  second  bicuspid  teeth  of  either  side. 
The  soft  parts  connecting  the  upper  lip  and  nose 
to  the  bone  are  divided  without  damaging  the 
skin,  and  the  flap  is  dissected  up  until  the  nares 
are  sufficiently  exposed. 

Posterior  nares.— If  a  little  mirror,  some- 
what similar  to  that  used  in  laryngoscopy, 
be  cautiously  introduced  behind  the  soft  palate 
through  the  mouth,  and  illumined  from  the  mouth, 
the  following  parts  may,  in  favourable  circum- 
stances, be  seen,  viz.  the  posterior  nares,  the 
septum,  the  middle  turbinated  bone  (middle 
concha),  part  of  the  superior  and  inferior  tur- 
binated bones  (conchse),  and  part  of  the  inferior 
meatus.  The  middle  meatus  is  well  seen,  and 
also  the  Eustachian  tube,  and  the  mucous  mem- 
brane of  the  upper  part  of  the  pharynx. 

This  mode  of  examination  is  very  difficult  to 
carry  out,  and  is  known  as  posterior  rhinoscopy. 
The  parts  just  named  can  all  be  felt  by  the  finger 
introduced  behind  ^the  soft  palate  through  the 
mouth.  The  posterior  nares  are  often  plugged  to 
arrest  severe  bleeding  from  the  nose,  and  in  order 
to  cut  a  proper-sized  plug  it  is  desirable  to  bear 
in  mind  the  dimensions  of  the  apertures.  Each 
aperture  is  of  regular  shape,  and  measures  about 
|^an  inch  transversely  by  1|  inches  in  the  vertical 
direction  in  a  well-developed  adult  skull. 

As  regards  the  nasal  cavities  generally,  it  is 
well  to  note  that  the  floor  is  wider  at  the  centre 
than  at  either  end,  that  the  vertical  diameter  is 


vi]  NASAL  CAVITIES  107 

greater  than  the  transverse,  and  is  also  greatest 
about  the  centre  of  the  fossae.  Forceps  introduced 
into  the  nose,  therefore,  are  most  conveniently 
opened  if  opened  vertically.  The  width  of  the 
fossae  increases  somewhat  from  above  downwards; 
thus  the  superior  turbinated  bone  is  only  2  mm. 
from  the  septum,  while  a-  space  of  from  4  to 
5  mm.  intervenes  between  the  inferior  turbinated 
bone  and  the  septum.  The  nasal  cavity  is  so  very 
narrow  above  the  middle  turbinated  bone  that 


MlD.TURB. 


U^P^*      WBU-J 

Fig.  26.— Transverse  vertical  section  of  the  nasal  cavities 
and  accessory  sinuses. 


and  accessory  sinuses 

that  bone  really  forms  the  surgical  roof  of  the 
nasal  fossae. 

The  shape  and  proportions  of  the  nasal 
cavity  in  the  child  are  peculiar.  In  the  adult 
the  inferior  meatus  is  large  (Fig.  26),  and  con- 
stitutes the  chief  respiratory  passage ;  in  the  young 
child  the  inferior  meatus  is  relatively  very  small, 
the  middle  meatus  affording  the  main  space  for  the 
respiratory  tide  (Lack).  The  nasal  cavities  grow 
rapidly  from  the  sixth  to  the  eighteenth  year ; 
during  this  period  the  permanent  dentition  is 
being  formed,  necessarily  causing  an  increase  in 


108  THE    HEAD    AND    NEGK  [CHAP. 

the  size  of  the  palate  and  of  the  floor  of  the  nose ; 
at  the  same  time  the  development  of  the  maxillary 
sinus  leads  to  an  increase  in  the  vertical  height 
of  the  nose,  this  increase  affecting  the  lower  or 
maxillary  much  more  than  the  ethmoidal  or  olfac- 
tory part  of  the  cavity.  Growth  of  the  nasal 
cavities  and  of  the  face  may  be  arrested  or  viti- 
ated by  any  obstruction  to  the  free  passage  of  the 
breath  through  the  nose;  the  most  common  cause 
of  obstruction  is  the  formation  of  adenoids  in  the 
naso-pharynx. 

By  referring  to  the  relations  of  the  nasal  fossae 
(Figs.  26,  27)  it  will  be  understood  that  inflam- 
mation of  the  lining  membrane  (coryza)  may  ex- 
tend to  the  pharynx  via  the  posterior  nares ;  may 
extend  up  the  Eustachian  tube  and  cause  some 
deafness;  may  reach  the  lacrimal  sac  and  con- 
junctiva through  the  naso-lacrimal  duct;  and  may 
extend  to  the  frontal  and  maxillary  sinuses, 
producing  frontal  headache  and  cheekache.  These 
relationships  are  often  demonstrated  in  a  severe 
"  cold  in  the  head."  From  the  nearness  of  the 
nasal  fossae  to  the  cranial  cavity  it  happens  that 
meningitis  has  followed  upon  purulent  inflam- 
mations of  the  nose.  Micro-organisms  which  give 
rise  to  inflammation  of  the  meninges  of  the  brain 
apparently  find  their  way  from  the  mucous  lining 
of  the  nose  to  the  cranial  cavity  along  minute 
blood-  and  lymph-vessels  which  traverse  the  cribri- 
form plates  with  the  olfactory  nerves.  Foreign 
bodies  of  various  kinds  are  often  lodged  in  the 
nose,  and  may  remain  there  for  some  years. 
Thus,  Tillaux  reports  the  case  of  an  old  woman 
aged  64  from  whose  nose  he  removed  a  cherry- 
stone that  had  been  there  for  twenty  years. 

In  washing  out  the  nasal  cavities  with  the 
"  nasal  douche"  the  fluid  is  introduced  by  means 
of  a  siphon.  The  nozzle  of  the  siphon  tube  is 
introduced  into  one  nostril,  the  mouth  is  kept 
open,  and  the  fluid  runs  through  that  nostril, 
passes  over  the  soft  palate,  and  escapes  from  the 
other  nostril.  The  latter  cavity  is  therefore 


vi]  NASAL  CAVITIES  109 

washed  out  from  behind  forwards.  The  course  of 
the  fluid  depends  upon  the  fact  that  when  the 
mouth  is  kept  open  there  is  such  a  disposition  to 
breathe  through  it  alone  that  the  soft  palate  is 
drawn  up  and  the  nares  cut  off  from  the  pharynx. 

The  roof  of  each  nasal  fossa  is  very  narrow, 
being  only  about  ^  of  an  inch  in  width  (Fig.  26). 
It  is  mainly  formed  by  the  thin  cribriform  plate, 
but  its  width  is  such  that  the  danger  of  the 
roof  being  penetrated  by  so  large  an  object  as  a 
pair  of  polyp  forceps  has  been  greatly  exaggerated. 
The  cranial  cavity  has,  however,  been  opened  up 
through  the  roof  of  the  nose  by  penetrating  bodies 
introduced  by  accident  or  with  homicidal  intent. 
Meningitis  has  followed  inflammation  of  the 
nasal  fossae,  the  inflammation  extending  through 
the  cribriform  plate.  Through  the  perineural 
and  perivascular  sheaths  the  lymphatic  system 
of  the  nose  is  in  continuity  with  that  of  the 
meninges,  and  by  these  channels  infections  may 
spread  from  the  roof  of  the  nose  to  the  mem- 
branes of  the  brain.  Fracture  of  this  part  also 
has  been  associated  with  very  copious  escape  of 
cerebro-spinal  fluid  through  the  nostrils.  A  men- 
ingocele  may  protrude  through  the  nasal  roof. 
Tn  a  case  reported  by  Lichtenberg  the  mass  hung 
from  the  mouth,  having  passed  through  a  congeni- 
tal fissure  in  the  palate.  It  was  mistaken  for  a 
polyp,  was  ligatured,  and  death  resulted  from 
intracranial  inflammation. 

The  septum  is  seldom  quite  straight  in 
adults;  the  deviation  being  more  often  towards 
the  left.  t  It  is,  however,  straight  in  children, 
and  remains  so  up  to  the  seventh  year.  In  adults 
the  septum^  deviates  in  76  per  cent,  of  all  persons. 
The  deviation  may  follow  an  injury.  It  has  been 
pointed  out  that  a  deviation  of  the  septum  may 
seriously  interfere  with  the  singing  voice.  The 
nose  also  is  seldom  quite  straight,  and  French 
authors  ascribe  this  to  some  deviation  of  the  sep- 
tum, often  dependent  upon  the  practice  of  always 
blowing  the  nose  with  the  same  hand.  If  the 


110  THE    HEAD    AND    NEOK  [CHAP. 

deviation  of  the  septum  be  considerable,  it  may 
more  or  less  block  one  nostril,  and,  until  the  oppo- 
site nostril  is  examined,  be  mistaken  for  a  septa! 
tumour  encroaching  upon  the  cavity.  The  flat- 
tened nose  in  acquired  syphilis  is  usually  due 
to  destruction  of  the  septum  and  more  or  less 
implication  of  the  adjacent  bones. 

Outer  wall  (Fig.  27). — The  inferior  nasal 
concha  may  interfere  with  the  introduction  of 
a  Eustachian  catheter  if  the  curve  of  the  instru- 
ment be  too  great.  The  anterior  end  of  the  bone 
is  about  |  of  an  inch  behind  the  orifice  of  the 
nostril.  The  opening  of  the  naso-lacrimal  duct 
is  about  1  inch  behind  the  orifice  of  the  nostril, 
and  about  f  of  an  inch  above  the  nasal  floor. 
This  opening  is  usually  slit-like  and  narrow. 
The  nasal  duct  pierces  the  nasal  mucous  mem- 
brane in  the  same  oblique  and  valvular  manner 
as  the  ureter  enters  the  bladder;  hence  the  nose 
can  be  blown  without  inflation  of  the  lacrimal 
sac.  The  height  of  the  inferior  meatus  is  about 
I  of  an  inch.  The  superior  meatus  is  a  very 
short  and  narrow  fissure,  and  into  its  upper 
and  fore  part  open  the  posterior  ethmoidal  cells. 
The  middle  meatus  opens  widely  in  front  upon  a 
part  of  the  outer  wall  called  the  atrium,  and, 
unless  care  be  taken  to  keep  the  point  of  any  in- 
strument well  towards  the  floor  of  the  fossa,  it 
is  easier  to  pass  the  instrument  into  the  middle 
than  into  the  inferior  meatus.  Upon  the  wall  of 
the  middle  meatus  is  a  deep  gutter  (the  hiatus 
semilunaris) ,  which  runs  from  above  downwards 
and  backwards  (Fig.  27).  Into  this  groove  open 
the  frontal  sinus  by  means  of  the  naso-f rental 
duct,  about  \  an  inch  long,  the  anterior  ethmoidal 
cells,  and,  near  its  posterior  end,  the  maxillary 
sinus.  The  rounded  aperture  of  the  frontal  sinus  is 
usually  situated  in  the  anterior  end  of  the  hiatus, 
but  not  infrequently  it  will  be  found  in  a  recess 
above  and  in  front  of  the  hiatus.  The  anterior 
ethmoidal  cells,  usually  two  in  number,  mlay  open 
into  the  hiatus,  the  naso-frontal  duct  (infundi- 


VI] 


OUTER  WALL 


NASAL  CAVITY       111 


bulum),  or  directly  into  the  anterior  part  of  the 
middle  meatus.  The  opening  of  the  maxillary  sinus 
may  occur  below,  instead  of  within,  the  posterior 
part  of  the  hiatus  semilunaris  (Fig.  27).  The 
upper  boundary  of  the  hiatus  is  formed  by  the 
bulla  ethmoidalis ;  its  lower  sharp  prominent 
margin  contains  the  uncinate  process  of  the  eth- 
moid. The  middle  ethmoidal  cell  is  seen  to  open 


PiTUITABy    FOSSA 


Fig.  27. — Outer  or  lateral  wall  of  the  nasal  cavity. 

The  greater  part  of  the  middle  turbinate  process  has  been  cut  away 
to  expose  the  hiatus,  bulla,  and  opening  of  the  infundibulum  or 
nasp-frontal  duct  and  maxillary  sinus.  A,  B,  indicate  the  two 
positions  at  which  the  opening  of  the  antrum  may  occur. 

on  the  bulla,  above  the  hiatus  semilunaris.  The 
level  of  the  hiatus  within  the  nose  may  be  indi- 
cated by  the  position  of  the  internal  palpebral 
ligament.  The  anterior  end  or  beak  of  the  middle 
turbinate  process  can  be  seen  distinctly  from  the 
anterior  nares,  when  the  interior  of  the  nose  is 
illuminated  by  reflected  light. 

The  width  of  the  nasal  floor    is   about  \   an 
inch,  or  a  little  over.     Its  smooth  surface  greatly 


112  THE    HEAD    AND    NECK  [OHAP. 

favours  the  passage  of  instruments  (Fig.  26).  It 
presents  a  gentle  slope  from  before  backwards. 
At  its  anterior  part  is  a  depression  of  mucous 
membrane  over  the  incisor  foramen.  This  foramen 
is  a  vestige  of  the  great  communication  that  once 
existed  between  the  cavities  of  nose  and  mouth. 

The  mucous  membrane  lining  the  nasal  cavi- 
ties is  covered  with  ciliated  epithelium  over  the 
lower  two-thirds  or  respiratory  part;  the  upper 
third — the  olfactory  part — is  covered  with  colum- 
nar epithelium,  while  the  vestibule  is  lined  with 
stratified  epithelium.  It  is  very  thick  and  vas- 
cular over  the  turbinate  bones  and  over  the  lower 
two-thirds  of  the  septum,  while  over  the  nasal 
floor  and  in  the  intervals  between  the  turbinate 
bones  it  is  very  much  thinner.  The  mucous 
membrane  lining  the  various  sinuses  and  the 
antrum  is  conspicuously  thin  and  pale.  The 
membrane  is  provided  with  many  glands,  which 
are  most  conspicuous  over  the  lower  and  hinder 
parts  of  the  outer  wall  and  over  the  posterior 
and  inferior  parts  of  the  septum.  These  glands 
may  be  the  subject  of  considerable  hypertrophy. 
They  are  capable  of  providing  also  a  very  copious 
watery  secretion,  which  has  in  some  cases  of 
chronic  coryza  following  injury  been  so  free  as 
to  be  mistaken  for  an  escape  of  cerebro-spinal 
fluid.  There  is  also  much  adenoid  or  lymphoid 
tissue  in  the  nasal  mucous  membrane,  which 
is  the  primary  seat  of  the  chief  scrofulous  affec- 
tions that  invade  this  part.  So  thick  and  lax 
is  the  normal  mucous  membrane  over  the  lower 
border  and  posterior  extremity  of  the  inferior 
turbinated  bones,  that  it  forms  a  kind  of  soft 
cushion,  sometimes  called  the  "  turbinate  body." 
This  condition  is  mainly  due  to  the  presence  of  a 
rich  submucous  venous  plexus,  the  vessels  of  which 
run,  for  the  most  part,  in  an  antero-posterior 
direction.  When  turgid  with  blood  it  swells  so 
as  to  obliterate  the  interval  between  the  bone  and 
the  septum.  When  the  seat  of  chronic  inflam- 
mation, the  mucous  membrane  over  the  inferior 


vi]  POLYPI  113 

bone  may  appear  as  a  polypoid  swelling.  The 
inspired  air  is  heated  as  it  passes  over  the  rich 
vascular  lining  membrane  of  the  nose;  it  is  also 
filtered,  the  dust  and  other  floating  particles  being 
deposited  on  the  moist  surface  of  the  conchse. 

Polypi  are  often  met  with  in  the  nose.  They 
are  of  two  kinds,  the  mucous  or  myxoraatous 
polyp  that  springs  usually  from  the  mucous  mem- 
brane beneath  or  over  the  middle  concha,  and 
the  fibrous  or  sarcomatous  polyp  that  usually 
takes  origin  from  the  periosteum  of  the  nasal 
roof  or  from  that  of  the  base  of  the  skull.  Polypi 
of  the  latter  kind  spread  in  every  available  direc- 
tion. They  expand  the  bridge  of  the  nose,  close 
the  nasal  duct  and  cause  epiphora,  depress  the 
hard  palate  and  encroach  upon  the  mouth,  in- 
vade the  antrum  and  expand  the  cheek,  grow 
down  into  the  pharynx,  pushing  forwards  the 
velum  palati,  and  may  penetrate  even  through  the 
inner  wall  of  the  orbit.  Such  tumours  may  be 
exposed  and  removed  by  separating  the  posterior 
and  inner  attachments  of  the  superior  maxilla, 
turning  it  forwards,  thus  exposing  the  nasal 
cavity  by  detaching  its  outer  wall.  The  bone  may 
be  replaced  in  situ  after  removal  of  the  tumour. 

The  foloocl  supply  of  the  nasal  cavity  is 
extensive,  and  is  derived  from  the  internal 
maxillary,  ophthalmic,  and  facial  arteries.  With 
regard  to  the  veins,  it  may  be  noted  that  the 
ethmoidal  veins  that  come  from  the  nose  enter 
the  ophthalmic  vein,  while  it  is  believed  by  some 
authorities  that  in  children  a  constant  commu- 
nication exists  between  the  nasal  veins  and  the 
superior  longitudinal  sinus  through  the  foramen 
caecum,  and  that  this  communication  may  be 
maintained  in  the  adult.  These  connexions  would, 
in  part,  explain  the  occurrence  of  intracranial 
mischief  as  a  consequence  of  certain  inflammatory 
affections  of  the  nasal  cavities.  Bleeding  from 
the  nose,  or  epistaxis,  is  a  common  and  often  a 
serious  circumstance.  Its  frequency  is  to  a  great 
extent  due  to  the  vascularity  of  the  mucous 


114  THE   HEAD    AND   NEOK  [CHAP. 

membrane,  to  its  laxity,  and  to  the  fact  that  the 
veins,  especially  those  over  the  lowest  (maxillary) 
turbinate  bone,  form  extensive  plexuses,  and  pro- 
duce a  kind  of  cavernous  tissue.  The  epistaxis 
is  often  due,  therefore,  to  interference  with  ^the 
venous  circulation,  as  seen  in  cases  of  cervical 
tumour  pressing  upon  the  great  veins,  in  the 
paroxysms  of  whooping-cough,  and  the  like.  The 
beneficial  effect  of  raising  the  arms  in  epistaxis 
is  supposed  to  depend  upon  the  extra  expansion 
of  the  thorax  so  produced,  and  the  aspiratpry 
effect  thus  brought  to  bear  upon  the  cervical  veins. 
The  bleeding  may  be  copious  and  long  continued. 
Thus,  Spencer  Watson  reports  a  case  where  the 
epistaxis  continued  on  and  off  for  twenty  months 
without  obvious  cause.  Martineau  mentions  an 
instance  in  which  12  Ib.  of  blood  was  lost  in  sixty 
hours,  and  Fraenkel  records  a  case  where  75  Ib. 
of  blood  is  said  to  have  escaped  from  first  to 
last.  In  several  instances  the  haemorrhage  has 
proved  fatal.  The  seat  of  the  bleeding  is  often 
not  easy  to  detect,  even  when  the  examination  is 
post  mortem.  In  many  cases  the  bleeding-point 
is  situated  on  the  septum,  ^  an  inch  above  and 
behind  the  nasal  spine. 

The  nerve  supply  of  these  parts  is  derived 
from  the  olfactory  nerve,  and  from  the  first 
and  second  divisions  of  the  fifth  nerve.  The 
lacrimation  that  often  follows  the  introduction 
of  irritants  into  the  nares  may  be*  explained 
by  the  fact  that  that  part  of  the  cavity  is  sup- 
plied freely  by  the  nasal  nerve,  a  branch  of  the 
ophthalmic  trunk.  As  an  example  of  transfer- 
ence of  nerve  force  in  the  opposite  direction  may 
be  noted  cases  where  a  strong  sunlight  falling 
upon  the  eyes  has  produced  an  attack  of  sneez- 
ing. Troubles  involving  the  vagal  centres,  such 
as  cough  and  bronchial  asthma,  have  followed 
affections  of  the  nasal  cavities;  relief  from  these 
troubles  has  been  obtained  by  cauterization  and 
anesthetization  of  the  mucous  membrane  over 
the  inferior  concha.  The  olfactory  nerves  are 


vi]  NASAL  SINUSES  116 

situated  in  the  upper  third  of  the  cavity,  and 
hence,  in  smelling  intently,  one  sniffs  deeply  and 
dilates  the  nostril.  The  inability  to  dilate  the 
nostril  in  facial  paralysis  may  explain  the  par- 
tial loss  of  smell  sometimes  noted  in  such  cases. 
Anosmia,  or  loss  of  the  sense  of  smell,  when  fol- 
lowing upon  an  injury  to  the  head,  may  be  due  to 
a  rupture  of  the  olfactory  nerve  fibres  as  they  pass 
through  the  cribriform  foramina.  The  olfactory 
roots  cross  the  edge  of  the  lesser  wings  of  the 
sphenoid,  and  in  falls  on  the  forehead  are  liable 
to  injury.  The  olfactory  centre  is  situated  in  the 
hippocampal  gyrus. 

Most  of  the  lymphatics  of  the  nasal  fossss 
enter  the  retropharyngeal  glands  placed  behind 
the  pharynx,  in  front  of  the  rectus  capitis  anti- 
cus  major.  Hence,  as  Fraenkel  has  pointed  out, 
"  retropharyngeal  abscess  may  arise  in  conse- 
quence of  diseases  of  the  nose."  Other  lympha- 
tics go  to  the  submaxillary,  parotid,  and  upper 
deep  cervical  lymph-glands,  and  it  is  common  to 
find  these  enlarged  in  nose  affections,  especially  in 
the  scrofulous.  The  lymphatics  of  the  nose  also 
communicate  with  those  of  the  meninges  through 
the  cribriform  plate. 

Nasal  sinuses.— Of  late  years  a  knowledge 
of  the  anatomy  and  relationships  of  the  ac- 
cessory sinuses  of  the  nose  has  become  of  the 
utmost  importance  to  the  surgeon.  Over  15  per 
cent,  of  the  subjects  examined  in  the  dissecting 
room  of  the  London  Hospital  show  disease  of  one 
or  more  of  these  sinuses;  Sir  StClair  Thomson 
estimates  that  the  sphenoidal  sinus  is  the  seat 
of  disease  in  30  per  cent,  of  aged  individuals. 
The  collective  capacity  of  the  accessory  sinuses — 
the  maxillary,  frontal,  sphenoidal,  and  ethmoidal 
—is  more  than  twice  that  of  the  nasal  cavity 
(Braune).  No  satisfactory  explanation  has  yet 
been  found  of  their  use,  except  to  give  mass 
without  adding  to  the  weight  of  the  face.  They 
may,  as  Dr.  James  Adam  has  supposed,  aid  in 
rendering  the  inspired  air  warm  and  moist. 


116 


THE    HEAD    AND    NECK 


[CHAP. 


The  frontal  sinus  is  extremely  variable  in  size 
and  shape.  The  surface  markings  shown  in  Fig.  28 
indicate  the  average  development  in  the  adult;  the 
opening  of  the  fronto-nasal  duct  or  infundibulum 
is  shown  in  Fig.  27.  Large  frontal  sinuses  do 
not  necessarily  imply  large  external  prominences 


Fig.  28. — Surface  markings  of  the  frontal  and  maxillary 
sinuses. 

A,  Ij  "  above  the  nasion  ;  B,  on  the  supraorbital  margin,  at  the 
junction  of  the  middle  and  outer  thirds  ;  C,  on  the  infraorbital 
margin  to  the  outer  side  of  the  lacrimal  sac  ;  D,  on  the  centre  of 
the  cheek-bone  in  line  with  the  outer  margin  of  the  orbit ;  E, 
over  the  second  bicuspid ;  F,  over  the  last  molar.  The  points 
A,  B,  and  Nasion  give  the  surface  position  of  the  frontal  sinus  ; 
C,  D,  E,  F,  that  of  the  maxillary  sinus. 

over  the  glabella  and  superciliary  eminences.     One 
sinus  may  develop   at  the  expense  of  the  other, 


vi]  FRONTAL  SINUS  117 

and  the  septum  may  be  displaced.  They  are 
larger  in  men  than  in  women.  They  are  absent 
on  one  side  in  9  per  cent,  of  cases,  and  on 
both  sides  in  7  per  cent.  (Logan  Turner).  It 
is  obvious  that  a  depressed  fracture  may  exist 
over  a  frontal  sinus  without  the  cranial  cavity 
being  damaged.  In  such  cases  the  inspissated 
contents  of  the  sinus  have  been  mistaken  for 
brain  matter  escaping.  Since  the  sinuses  are  in 
communication  with  the  nose,  much  emphysema 
may  follow  upon  the  fracture  of  the  sinus  wall. 
Insects  have  found  their  way  into  these  cavities. 
"  Centipedes  are  particularly  liable  to  be  found 
in  the  frontal  sinuses,  where  they  may  remain  for 
years,  the  secretions  of  these  cavities  furnishing 
them  with  sufficient  nourishment "  (Fraenkel). 
Larvae  have  also  been  found  here,  and  maggots 
that  have  developed  within  the  nose  have  managed 
to  make  their  way  to  the  frontal  sinuses. 

The  frontal  sinus  is  merely  a  bud  or  rudiment 
in  early  childhood.  About  the  sixth  year  the  bud 
of  mucous  membrane  grows  out  from  the  neigh- 
bourhood of  the  anterior  end  of  the  hiatus,  and 
gradually  insinuates  its  growing  extremity  into 
the  diploe  of  the  frontal  bone,  separating  the 
inner  from  the  outer  osseous  table.  It  reaches  its 
full  size  about  the  twenty-fifth  year ;  the  stalk  of 
the  outgrowth  becomes  the  fronto-nasal  duct;  it 
leads  from  the  posterior  part  of  the  sinus.  The 
duct  is  |  of  an  inch  long,  and  runs  downwards 
and  slightly  backwards  to  open  at  or  near  the 
anterior  end  of  the  hiatus  semilunaris.  Along  the 
hiatus  the  secretion  of  the  frontal  sinus  may  be 
conveyed  to  the  antrum,  thus  converting  that 
cavity  into  a  cesspool  in  cases  of  chronic  suppura- 
tion of  the  frontal  sinus  (Fig.  27).  The  fronto- 
nasal  duct  is  frequently  tortuous,  and  even  after 
the  beak  of  the  middle  turbinate  process  is  removed 
it  is  not  easy  to  catheterize  from  below.  Hence,  in 
cases  of  obstruction,  the  frontal  sinus  is  trephined 
over  the  glabella,  or  at  the  superior  internal  angle 
of  the  orbit  (Tilley),  and  a  probe  passed  down- 


118  THE    HEAD    AND    NECK  [CHAP. 

wards  and  slightly  backwards  to  drain  the  sinus 
into  the  nose. 

The  anterior  ethmoidal  cells  commonly  open 
into  the  fronto-nasal  duct,  and  hence  they  are 
usually  involved  in  any  disease  affecting  the 
frontal  sinus.  The  frontal  diploic  vein,  which 
joins  the  frontal  vein  at  the  supraorbital  notch, 
receives  blood  from  the  frontal  sinus.  In  cases 
of  frontal  suppuration,  infection  may  spread 
rapidly  in  the  frontal  bone  by  means  of  the 
veins  of  the  diploe,  setting  up  a  destructive  form 
of  osteitis  and  meningitis. 

The  sphenoidal  sinus  opens  on  the  roof  of 
the  nose,  behind  the  superior  meatus  (Fig.  27) ; 
it  is  developed  at  the  same  period  of  life  as  the 
frontal  sinus.  It  is  deeply  placed,  and  not  very 
accessible  for  operation  when  the  seat  of  disease. 
It  is  frequently  the  seat  of  chronic  suppuration 
set  up  by  infections  from  the  nose.  Its  anterior 
wall,  which  is  comparatively  thin,  is  situated  be- 
tween 7  and  8  cm.  from  the  lower  margin  of  the 
anterior  nares.  Tilley  recommends  the  mid-point 
of  the  lower  border  of  the  middle  turbinate  as  a 
guide  to  the  opening  of  the  sphenoidal  sinus. 
The  nasal  septum  also  serves  as  a  safe  guide,  for 
its  vomerine  part  is  implanted  on  the  anterior 
wall  of  the  sinuses.  A  probe  directed  to  this 
point  from  the  floor  of  the  anterior  nares  will, 
if  passed  straight  onwards,  reach  the  opening 
of  the  sinus  at  the  depth  mentioned  above — 
7  to  8  cm. 

In  close  contact  with  the  thin  lateral  wall  of  this 
sinus  there  ^are  certain  extremely  important  struc- 
tures;  Besides  the  cavernous  sinus  and  internal 
carotid  artery,  the  optic  nerve  and  second  division 
of  the  fifth  nerve  are  in  the  closest  contact,  and 
may  be  affected  in  sinusitis  (Fig.  32,  p.  131).  On 
the  roof  is  the  pituitary  body;  tumours  of  this 
body  may  invade  the  sinus.  Its  veins  join  the 
ethmoidal.  The  walls  of  the  sinuses  are  thin  and 
easily  perforated,  as  a  case  which  occurred  at 
the  London  Hospital  will  show.  A  man  stumbled 


vi]  MAXILLARY  SINUS  119 

forwards  on  his  umbrella  as  he  left  a  public- 
house  in  Whitechapel,  the  point  entering  his 
face  above  the  bicuspid  teeth.  He  walked  to  the 
hospital,  and  died  three  days  afterwards.  The 
ferrule  of  the  umbrella  was  found  embedded  in 
the  pons,  the  point  having  traversed  the  maxillary 
and  sphenoidal  sinuses. 

The  maxillary  sinus  (antrum  of  Highmore) 
exists  at  birth,  but  attains  its  largest  dimensions 
in  old  age.  The  surface  markings  for  indicating 
its  position  on  the  face  are  given  in  Fig.  28. 
The  walls  of  the  cavity  are  thicker  in  children 
than  in  adults.  Tumours  of  various  kinds  are 
apt  to  develop  in  this  cavity,  and  to  distend 
its  walls  in  various  directions.  Thus  the  growth 
breaks  through  the  thin  inner  wall  and  invades 
the  nose,  it  pushes  up  the  roof  of  the  cavity  and 
invades  the  orbit  (see  Fig.  26,  p.  107),  it  encroaches 
upon  the  mouth  through  the  floor  of  the  sinus, 
and  makes  its  way  also  through  the  somewhat 
slender  anterior  wall  into  the  cheek.  The  densest 
part  of  the  sinus  wall  is  that  in  relation  to  the 
malar  bone,  and  this  part  does  not  yield.  There 
is  little  inducement  for  any  growth  to  spread 
backwards,  although  it  sometimes  invades  the 
zygomatic  and  pterygo-maxillary  fossae.  As  the 
infraorbital  nerve  runs  along  the  roof  of  the 
sinus,  while  the  nerves  of  the  upper  teeth 
are  connected  with  its  walls,  these  structures  are 
pressed  upon  in  growths  springing  from  the 
sinus,  and  thus  neuralgia  of  the  face  and  teeth 
is  often  produced.  In  individuals  who  have  suf- 
fered from  adenoids  the  growth  of  the  sinus  is 
arrested. 

In  the  operation  of  tapping  the  antrum  a  ^spot 
is  usually  selected  just  above  the  second  bicus- 
pid^ tooth,  since  the  bone  is  here  thin  and  is  con- 
veniently reached.  In  some  cases  it  is  sufficient 
to  extract  one  of  the  molar  teeth,  since  the  fangs 
of  these  often  enter  the  cavity  of  the  sinus.  The 
tooth  usually  selected  is  either  the  first  or  the 
third  molar.  Not  infrequently  the  sinus  com- 


120  THE    HEAD    AND    NECK 

municates  at  its  upper  anterior  part  with  the 
frontal  sinus.  From  Fig.  26  it  will  be  seen  that 
the  antra  descend  below  the  level  of  the  palate, 
and  cannot  be  efficiently  drained  by  an  opening 
made  above  t  the  palatal  level. 

The  opening  of  the  maxillary  sinus  is  shown  in 
Figs.  26,  27;  it  is  on  a  level  with  the  roof  of  the 
cavity  :  hence  if  pus  be  present  it  drains  most  freely 
when  the  head  is  turned  so  that  the  affected  chamber 
is  uppermost.  The  sphenoidal  sinus  empties  most 
easily  when  the  head  is  bent  forwards;  the  frontal, 
when  the  head  is  thrown  backwards.  The  cavity 
of  the  antrum  is  small  if  the  inferior  meatus  is 
large  or  if  the  canine  fossa  of  the  face  is  well 
marked.  The  lymphatics  of  the  sinuses  drain 
into  the  retropharyngeal  glands.  As  the  result  of 
a  fall,  one  of  the  upper  teeth  has  been  entirely 
driven  into  the  antrum  and  lost  to  view.  In  one 
case  an  upper  incisor  was  found  lying  loose  in 
the  antrum  three  and  a  half  years  after  the 
accident  that  had  driven  it  there. 


CHAPTER     VII 
THE    FACE 

THE  parts  of  the  face,  other  than  those  already 
dealt  with,  will  be  considered  under  the  fol- 
lowing heads : 

1.  The  face  generally. 

2.  The  parotid   region. 

3.  The  upper  and  lower  jaws,  and  parts  con- 

nected with  them. 

The  lips  will  be  considered  with  the  cavity  of 
the  mouth  (Chap.  vin.). 

1.   THE  FACE  GENERALLY 

The  skin  of  the  face  is  thin  and  fine,  and 
is  more  or  less  intimately  adherent  by  a  deli- 
cate subcutaneous  tissue  to  the  parts  beneath. 
The  skin  generally  is  very  freely  supplied  with 
sebaceous  and  sudoriparous  glands,  and  hence 
the  face  is  frequently  the  seat  of  acne,  an 
eruption  that  especially  involves  the  sebaceous 
follicles.  From  the  thinness  of  the  skin,  and 
from  the  absence  of  dense  fasciae,  facial  abscesses 
usually  soon  point  and  seldom  attain  large  size. 

The  cellular  tissue  of  the  face  is  lax,  and 
readily  lends  itself  to  spreading  infiltrations,  so 
that  in  certain  inflammatory  affections  the  cheeks 
and  other  parts  of  the  face  may  become  greatly 
swollen.  In  general  dropsy,  also,  the  face  soon 
becomes  "puffy,"  the  change  first  appearing  as 
a  rule  in  the  lax  tissue  of  the  lower  eyelid.  The 
skin  over  the  chin  is  peculiarly  dense  and  adherent 
to  the  parts  beneath,  and  in  most  respects  closely 
resembles  the  integument  of  the  scalp.  When  such 
121 


122  THE    HEAD    AND    NECK  [CHAP. 

parts  of  the  integuments  of  the  face  as  cover 
prominent  bones,  such  as  the  malar  bone,  chin, 
and  the  supraorbital  margin,  are  struck  by  a 
blunt  instrument  or  in  a  fall,  the  wound  pro- 
duced has  often  the  appearance  of  a  clean  incised 
wound,  just  as  obtains  in  contused  wounds  of  the 
scalp. 

The  mobility  of  the  facial  tissues  renders  this 
part  very  suitable  for  the  performance  of  plastic 
operations  of  various  kinds,  and  their  vascularity 
generally  ensures  a  ready  and  sound  healing. 
Although  there  is  a  large  quantity  of  fat  in 
the  subcutaneous  tissue  of  this  region,  fatty 
tumours  are  singularly  rare  upon  the  face.  They 
appear,  indeed,  to  avoid  this  region.  Thus,  M. 
Denay  reports  the  case  of  a  man  who  had  no  fewer 
than  215  fatty  tumours  over  different  parts  of 
his  body,  but  not  one  upon  his  face.  The  face  is 
peculiarly  liable  to  be  the  seat  of  certain  ulcers, 
especially  rodent  and  lupous  ulcers,  and  is  the 
part  most  often  attacked  by  malignant  pustule 
(anthrax),  a  disease  transmitted  to  man  from 
cattle  afflicted  with  a  malady  known  in  this 
country  as  splenic  fever,  and  in  France  as 
char b on. 

Blood  supply. — The  tissues  of  the  face  are 
very  vascular,  and  are  liberally  supplied  with 
blood-vessels  in  all  parts.  The  facial  arterioles 
have  a  particularly  rich  supply  of  vaso-motor 
nerves,  which  are  derived  from  the  sympathetic 
system,  reaching  the  facial  artery  through  the 
superior  cervical  ganglion.  In  blushing,  the 
vaso-dilator  fibres  are  stimulated  by  an  emotional 
disturbance.  The  finer  vessels  of  the  skin  often 
appear  permanently  injected  or  varicose  in  the 
drunken,  or  in  those  who  are  much  exposed 
to  cold,  or  are  the  subjects  of  certain  forms  of 
acne.  Nsevi  and  the  various  forms  of  erectile 
tumour  are  common  about  the  face.  For  a 
like  reason  also  wounds  of  the  face,  while  they 
may  bleed  readily  when  inflicted,  are  apt  to  heal 
with  singular  promptness  and  accuracy.  All 


vii]          BLOOD  SUPPLY   OF  THE.  FACE  123 

wounds,  therefore,  of  this  part  should  have  their 
edges  carefully  adjusted  as  soon  after  the  accident 
as  possible.  Extensive  flaps  of  skin  that  have 
been  torn  up  in  lacerated  wounds  often  retain 
their  vitality  in  almost  as  marked  a  manner  as 
do  like  flaps  torn  from  the  scalp.  Extensive 
injuries  to  the  face  associated  with  great  loss 
of  substance  are  often  repaired  in  a  remarkable 
manner,  and  such  injuries  may  not  be  immediately 
fatal,  as  a  case  reported  by  Longmore  shows : 
"An  officer  of  Zouaves,  wounded  in  the  Crimea, 
had  his  whole  face  and  lower  jaw  carried  away 
by  a  ball,  the  eyes  and  tongue  included,  so  that 
there  remained  only  the  cranium,  supported  by 
the  neck  and  spine."  He  lived  twenty  hours. 

The  pulsations  of  the  facial  artery  can  be  best 
felt  at  the  lower  border  of  the  jaw,  where  the 
vessel  crosses  just  in  front  of  the  anterior  border 
of  the  masseter  muscle.  It  is  here  covered  only 
by  the  integument  and  the  platysma,  and  can  be 
readily  compressed  against  the  bone  or  ligatured. 
The  anastomoses  of  the  artery  upon  the  face  are 
so  free  that,  when  the  vessel  is  divided,  both  ends, 
as  a  rule,  require  to  be  secured.  The  facial  vein 
is  only  in  contact  with  the  artery  near  the  lower 
border  of  the  jaw ;  on  the  face  it  is  separated  from 
it  by  a  considerable  interval.  The  vein  is  not  so 
flaccid  as  are  most  superficial  veins;  it  remains 
more  patent  after  section,  it  possesses  no  valves, 
and  communicates  at  one  end  indirectly  with  the 
cavernous  sinus,  and  at  the  other  with  the  inter- 
nal jugular  vein  in  the  neck.  This  vein  has  also 
another,  but  less  direct,  communication  with  the 
intracranial  veins.  It  is  as  follows  :  the  facial  vein 
receives  the  "deep  facial  vein"  from  the  ptery- 
goid  plexus,  and  this  plexus  communicates  with 
the  cavernous  sinus  by  means  of  some  small  veins 
which  pass  through  the  foramen  ovale  and  the 
fibrous  tissue  of  the  foramen  lacerum  medium. 
These  dispositions  of  the  facial  vein  may  serve 
to  explain  the  mortality  of  some  inflammatory 
affections  of  the  part.  Thus,  carbuncle  of  the  face 


124  THE    HEAD    AND    NECK  [CHAP. 

is  not  infrequently  fatal  by  inducing  thrombosis 
of  the  cerebral  sinuses,  and  a  like  complication 
may  occur  in  any  other  diffuse  and  deeply  extend- 
ing inflammatory  condition. 

A  reference  to  the  development  of  the  face 
assists  to  explain  the  distribution  of  the  fifth 
nerve  and  the  occurrence  of  certain  abnormalities 
(Fig.  29).  The  face  is  developed  from  five  pro- 
cesses, a  mesial,  the  fronto-nasal,  and  two  lateral 
— the  maxillary  and  mandibular.  The  fronto 


Fig.  29.  -  Showing  the  development  of  the  face. 

F.N.P.,  Part  formed  from  the  fronto-nasal  process  ;  L.,  from  its  lateral, 
and  M.,  from  its  mesi;il  parts  ;  MAX.,  formed  by  the  maxillary 
process  ;  MAN.,  formed  by  the  mandibular  process. 

nasal  process  forms  the  middle  part  of  the  upper 
lip  and  the  nose.  It  may  fail  to  develop  :  thus 
the  condition  of  cyclops  is  produced.  It  springs 
from  the  frontal  region  and  carries  with  it  a 
branch  of  the  first  division  of  the  fifth,  the  nasal 
nerve.  The  second  division  of  the  fifth  is  the 
nerve  of  the  maxillary  process,  while  the  third  is 
that  of  the  mandibular. 

JVerve    supply. — The  nerves  of  the  face  are 
very    liberally    distributed,    the    fifth    being    the 


vii]          NERVE  SUPPLY   OF   THE   FACE  125 

sensory  nerve,  the  facial  the  motor  (Fig.  2,  p.  11). 
It  follows,  from  the  great  number  of  nerve  fila- 
ments about  the  part,  and  the  extensive  sensory 
nucleus  of  the  fifth  nerve,  that  severe  irritants 
applied  to  the  face  may  set  up  a  widespread  nerve 
disturbance  (Fig.  31,  p.  129).  Dr.  George  Johnson 
mentions  a  case  where  a  piece  of  flint  embedded 
in  a  scar  on  the  cheek  set  up  facial  neuralgia, 
facial  paralysis,  and  trismus,  and  induced  a 
return  of  epileptic  attacks. 

The  positions  of  the  supra-  and  infraorbital 
foramina  and  of  the  mental  foramen  and  of 
the  exit  of  the  corresponding  nerves  are  indi- 
cated as  follows :  The  supraorbital  foramen  is 
found  at  the  junction  of  the  inner  with  the  middle 
third  of  the  upper  margin  of  the  orbit.  A  straight 
line  drawn  downwards  from  this  point  so  as  to 
cross  the  gap  between  the  two  bicuspids  in  both 
jaws  will  cross  both  the  infraorbital  and  mental 
foramina.  The  infraorbital  foramen  is  a  little 
over  \  of  an  inch  below  the  margin  of  the  orbit. 
The  mental  foramen  in  the  adult  is  midway  be- 
tween the  alveolus  and  the  lower  border  of  the 
jaw,  and  is  a  little  over  £  of  an  inch  below  the 
cul-de-sac  of  mucous  membrane  between  the  lower 
lip  and  jaw.  At  puberty  the  foramen  is  nearer 
fco  the  lower  border  of  the  maxilla,  and  in  old  age 
it  is  close  to  the  alveolus.  The  infraorbital  nerve 
has  been  divided  for  neuralgia  at  its  point  of  exit, 
the  nerve  being  reached  either  by  external  incision 
or  through  the  mouth  by  lifting  up  the  cheek.  In 
other  cases  the  floor  of  the  orbit  has  been  exposed, 
the  infraorbital  canal  (the  anterior  half  of  which 
has  a  bony  roof)  has  been  opened  up,  and  large 
portions  of  the  trunk  of  the  nerve  have  been  in 
this  way  resected.  The  spheno-palatine  (Meckel's 
ganglion)  has  been  repeatedly  excised  for  the  relief 
of  neuralgia  involving  the  second  division  of  the 
fifth  nerve.  A  triangular  flap  of  skin  is  turned 
up  from  the  front  of  the  cheek,  and  the  infra- 
orbital  foramen  is  exposed.  The  anterior  wall  of 
the  antrum  is  opened  with  a  trephine,  and  the  bone 


126  THE    HEAD    AND    NECK  [CHAP 

is  cut  away  from  the  floor  of  the  infraorbital 
groove  so  that  the  nerve  lying  in  that  canal  is 
fully  exposed.  The  nerve  is  followed  back  to  the 
posterior  wall  of  the  antrum.  This  wall  having 
been  trephined,  the  spheno-maxillary  (pterygo- 
palatine)  fossa  is  opened  up  and  Meckel's  ganglion 
exposed  (Fig.  30).  Beyond  the  ganglion  the  fora- 
men rotundum  can  be  made  out.  The  infraorbital 
artery  runs  with  the  nerve,  and  that  vessel,  to- 


3RD     DlV, 

EXT.  PTERYGOID   PLATE      \ 
SPHENO-MAX.    FOSSA 


Fig.  30. — Surface  markings  for  the  second  and  third 
divisions  of  the  fifth  nerve. 

gether  with  its  anterior  dental  branch  to  the 
incisor  and  canine  teeth,  will  probably  be  divided. 
The  infraorbital  vein  ends  in  the  pterygoid 
plexus.  The  ganglion  is  surrounded  by  the  ter- 
minal branches  of  the  internal  maxillary  artery. 
It  is  a  triangular  body,  with  a  diameter  of  about 
i  of  an  inch.  It  is  a  little  convex  on  its  outer 
side,  and  is  of  reddish  colour. 

Operations  such  as  that  just  described  serve  to 
recall  the  relationship  of  parts,   but  in  practice 


vn]          NERVE   SUPPLY   OF   THE   FACE  127 

they  are  now  replaced  by  the  simpler  means 
of  hypodermic  injections.  Absolute  alcohol,  in- 
troduced into  the  trunk  of  a  nerve,  produces 
anaesthesia  in  the  area  of  its  distribution  for  six 
months  or  more.  The  successful  performance  of 
such  injections  requires  a  very  accurate  knowledge 
of  the  position  and  course  of  the  nerves,  and 
also  of  surrounding  structures.  The  course  of 
the  second  division  of  the  fifth  nerve  is  shown 
in  Fig.  30.  A  point  on  the  upper  border  of  the 
zygoma,  6  mm.  (|  inch)  behind  the  ascending 
margin  of  the  malar,  lies  directly  over  the  upper 
part  of  the  spheno-maxillary  fossa  which  con- 
tains the  second  division  of  the  fifth  nerve  and 
Meckel's  ganglion.  To  reach  the  nerve  the  needle 
has  to  be  introduced  37  mm.  (1^  inches).  An 
easier  and  safer  route  is  along  the  floor  of  the 
orbit.  The  needle  is  inserted  at  the  mid-point  of 
the  lower  border  of  the  orbit,  and  pushed  back- 
wards along  the  floor,  parallel  to  the  sagittal 
plane  of  the  head.  The  needle  is  pushed  within 
the  spheno-maxillary  fossa  until  it  is  arrested 
by  coming  in  contact  with  the  sphenoid  at  or  near 
the  foramen  rotundum.  By  suitable  manoeuvring 
the  needle  can  be  felt  to  enter  the  foramen 
rotundum.  The  depth  of  the  foramen  rotundum 
from  the  margin  of  the  orbit  is  43  mm.  (If  inches). 
The  nerve  may  also  be  reached  by  introducing  the 
needle  at  the  upper  border  of  the  zygoma  just 
behind  the  malar  angle,  and  directing  it  inwards. 
The  ganglion  lies  at  a  depth  of  50  mm.  (2  inches) 
from  the  surface  (Symington). 

The  inferior  dental  nerve  has  been  divided 
at  the  mental  foramen  by  an  incision  made 
through  the  buccal  mucous  membrane  opposite  to 
the  roots  of  the  two  premolar  teeth.  Through  this 
incision  the  nerve  can  be  stretched  and  the  cuta- 
neous portion  of  it  excised.  The  nerve  has  been 
divided  in  the  following  manner  before  its  entry 
into  the  mandibular  (inferior  dental)  ^foramen^: 
The  mouth  being  held  widely  open,  an  incision  is 
made  from  the  last  upper  molar  to  the  last  lower 


128  THE    HEAD    AND    NECK  [CHAP. 

molar  just  to  the  inner  side  of  the  anterior  bor- 
der of  the  coronoid  process,  which  can  be  clearly 
denned  by  palpation.  The  cut  passes  through  the 
mucous  membrane  down  to  the  tendon  of  the  tem- 
poral muscle.  The  finger  is  introduced  into  the 
incision,  and  passed  between  the  ramus  of  the 
jaw  and  the  internal  pterygoid  muscle  until 
the  bony  point  is  felt  that  marks  the  orifice  of 
the  mandibular  (inferior  dental)  canal.  The  nerve 
is  here  picked  up  with  a  hook,  isolated,  and 
divided. 

The  buccal  nerve  supplies  the  mucous  membrane 
and  skin  of  the  cheek.  It  passes  forwards  on 
the  outer  surface  of  the  buccinator  muscle. 

The  trunk  of  the  third  division  of  the  fifth 
nerve  leaves  the  middle  fossa  of  the  skull  by  the 
foramen  ovale,  the  position  of  which  corresponds 
to  the  lower  border  of  the  zygoma  immediately 
anterior  to  the  eminentia  articularis  (Fig.  30). 
To  inject  the  trunk  of  the  nerve,  the  needle  is 
entered  at  this  point  and  guided  inwards  against 
the  under  surface  of  the  sphenoid  until  a  depth 
of  37  mm.  (1^  inches)  is  reached.  Sensations 
referred  along  the  nerve  will  tell  the  operator 
if  the  nerve  has  been  reached.  It  is  well  to 
direct  the  needle  a  little  forwards  as  well  as 
inwards,  for  it  will  be  then  arrested  by  the 
external  pfcerygoid  plate;  at  the  posterior  border 
of  this  plate  lies  the  foramen  ovale.  It  is  also 
possible,  by  directing  the  needle  in  a  more  upward 
and  backward  direction,  to  enter  the  foramen 
ovale  and  reach  the  Gasserian  (semilunar)  ganglion 
itself  (see  Fig.  32). 

When  a  sensory  nerve  is  divided,  the  area 
of  analgesia  which  results  does  not  correspond 
to  its  anatomical  distribution.  Thus,  when  the 
ophthalmic  division  of  the  fifth  cranial  nerve  is 
cut,  only  a  narrow  strip  of  skin  on  the  forehead  is 
completely  deprived  of  feeling,  whereas  from  the 
anatomical  distribution  one  would  infer  that  the 
skin  of  the  forehead  and  of  the  anterior  half  of 
the  scalp  would  be  involved  (see  Fig.  2,  p.  11).  If 


vn]       DIVISION    OF    A  SJENSORY    NERVE        129 

the  second  division  is  cut,  the  area  of  anaesthesia  is 
confined  to  a  narrow  space  between  the  orbit  and 
the  mouth;  on  section  of  the  third  division,, to  a 
strip  running  downwards  in  front  of  the  ear  and 
along  the  course  of  the  lower  jaw  (Head). 

Head  has  offered  an  explanation  of  the.  vary- 
ing results  which  follow  section  of  a  sensory 
nerve.  A  nerve  contains  three  kinds  of  sensory 
nerve  fibres  :  (1)  those  subserving  deep  sensibility 
— endowing  muscles,  bones,  ligaments,  joints,  and 
deep  structures  with  the  power  to  feel  pressure  and 


B; 


Fig.  31. — Diagnosis  showing  the  extent  of  loss  of  sensi- 
bility following  (A)  excision  of  the  Gasserian  gang- 
lion, (B)  section  of  the  second  cervical  nerve.  (After 

H.  H.  Tooth.) 

In  the  area  stippled  black  there  is  a  loss  of  protopathic  sensibility  ; 
in  that  stippled  red,  of  epicritic  sensibility. 

pain ;  (2)  those  subserving  protopathic  sensibility— 

by  which  the  skin  is  rendered,  sensitive  to  prick, 
and  to  temperature  if  it  be  above  40°  or  below 
22°;  (3)  those  subserving  epicritic  sensibility — by 
which  the  skin  is  endowed  with  the  power  of  feeling 
light  touch  (tested  with  such  a  substance  as  cotton- 
wool) and  finer  degrees  of  temperature.  Now,  in 
the  majority  of  instances,  when  a  nerve  is  divided, 
the  loss  of  epicritic  sensibility  corresponds  in  extent 
to  the  anatomical  distribution  of  the  nerve;  when 


130  THE    HEAD    AND    NECK  [CHAP. 

the  semilunar  or  Gasserian  ganglion  is  removed 
(see  Figs.  2  and  31),  the  loss  of  epicritic  sensibility 
corresponds  to  the  area  of  distribution,  but  the  loss 
of  protopathic  sensibility  is  less  than  the  anatomi- 
cal area.  It  is  evident  that  protopathic  fibres  from 
the  second  cervical  nerve  (Fig.  31)  invade  and  sup- 
ply the  area  of  skin  furnished  with  epicritic  sen- 
sibility by  the  fifth  nerve.  In  the  lower  part  of  the 
face  there  is  no  overlapping  of  areas  ;  in  the  mental 
branch  of  the  fifth,  the  epicritic  and  protopathic 
fibres  are  distributed  to  the  same  extent  of  skin. 
Thus  th6  effects  which  follow  section  of  a  sensory 
nerve  depend  on  the  nature  of  the  fibres  in  that 
nerve,  and  on  the  extent  of  skin  to  which  each 
kind  is  exclusively  distributed.  Even  after  the 
semilunar  ganglion  is  excised,  the  deep  structures 
of  the  face  are  sensitive  to  pressure;  that  is  due 
to  the  facial  nerve  containing  certain  afferent 
fibres  which  are  sensitive  to  pressure  (Maloney 
and  Kennedy). 

Excision  of  the  Gasserian  ganglion. — For  cases 
of  intolerable  and  intractable  neuralgia  Kose  pro- 
posed the  excision  of  the  semilunar  ganglion.  It 
is  the  sensory  ganglion  of  the  fifth  nerve,  and 
corresponds  to  the  ganglion  on  the  posterior 
root  of  a  spinal  nerve.  The  nerve  fibres  of  the 
fifth  necessarily  undergo  degeneration  when  it  is 
excised. 

The  operation  usually  performed  is  the  follow- 
ing (see  Fig.  32)  :  An  omega-shaped  flap  of  skin  is 
raised  from  the  temples,  having  the  zygoma  at 
its  base  and  the  temporal  ridge  at  its  convexity. 
The  tissues  are  reflected  down  to  the  floor  of  the 
temporal  fossa.  The  superficial  and  deep  temporal 
vessels  have  to  be  tied.  A  wide  trephine  opening  is 
made  in  the  squamosal  and  great  wing  of  the 
sphenoid  on  a  level  with  the  upper  border  of  the 
zygoma,  and  the  dura  mater  exposed.  This  is 
usually  followed  by  profuse  haemorrhage  from  the 
middle  meningeal  vessels  which  cross  the  field  of 
operation.  The  dura  mater  and  the  superimposed 
temporo-sphenoidal  lobe  are  raised  from  the  bone, 


vii]    EXCISION   OF   GASSERIAN   GANGLION     131 

when  the  third  and  second  divisions  of  the  fifth 
nerve  are  brought  into  view  as  they  escape  by 
the  foramen  ovale  and  foramen  rotundum.  They 
are  seen  to  spring  from  the  ganglion  situated 
over  the  apex  of  the  petrous  bone  and  on  the 
outer  wall  of  the  cavernous  sinus.  The  motor  root 
which  supplies  the  muscles  of  mastication  lies 
under  the  ganglion  and  should  not  be  cut.  The 
ganglion  is  embedded  in  the  dura  mater  and  sur- 
rounded by  a  prolongation  of  the  subarachnoid 


ISLAND  of  BEIL  * 
FISSURED 
DEEP  TCMP.FASCIA 

TEMP  MUSCLE 
FIRST  TBM 

UMCUS 

DURA  MATER 

fliD  MenmCEALAR 

ROOT  of ZYQONA 

EXT,  PTER/QOID 

MlO  flE 

IAT.  MAT..  ART 

MASSETER  __- - 
CORONOID  PROC  . 


OPTIC  TRACT 
5UBARACH/10ID  SPACE 
IV*1 

CAVER/IOUS  5i/ius 
I/IT  CAROTID  ART. 
VIth 

QASSERIAM  qAnqtiO 
SPHEROIDAL  SINUS 
3'd  DIV  OF  Vfh 
LAT.  RECESSopPrtAR 

EUSTACHIA/I  TUBB- 
LEVATOR  PAUATAE 


Fig.  32. — Coronal  section  to  show  the  depth  and  relation- 
ships of  the  Gasserian  or  semilunar  ganglion. 

space  (Meckcl's  space),  which  is  necessarily  opened. 
Only  the  part  of  the  ganglion  connected  with  the 
second  and  third  divisions  is  removed,  the  part 
connected  with  the  ophthalmic  division  being  left, 
as  it  is  firmly  embedded  in  the  outer  wall  of  the 
cavernous  sinus  and  inclose  proximity  to  the  inter- 
nal carotid  artery  and  the  oculo-motor  nerves. 
The  hippocampal  convolution  containing  the  olfac- 
tory centre  lies  immediately  over  the  ganglion 
(Fig.  32).  There  is  always  an  escape  of  cerebro- 


132 


THE   HEAD    AND   NEGK 


[CHAP. 


spinal    fluid    when    the    dural    sheath    is    opened 
(Cushing). 

The  eminentia  articularis  at  the  base  of  the 
zygoma  serves  as  a  useful  guide  to  the  position 
of  the  ganglion  ;  when  the  middle  fossa  is  opened 
and^  the  temporal  lobe  raised  up,  the  ganglion  will 
be  found  at  a  depth  of  2^  inches  and  in  the  same 


Sl/PHA-  ORBITAL  N. 


FRONTAL 
/VASAL   /V. 


NASAL  BRMCH 
fSENSORy) 


Fig.  33.  —  Diagram  to  show  the  proximity  of  the  sensory 
nuclei  of  the  fifth  and  tenth  cranial  and  first  and 
second  cervical  nerves.  (After  Peglcr.} 

coronal  plane  as  the  articular  eminence,  but  at  a 
higher  level.* 

To  understand  the  various  pains  which  arc 
so  frequently  referred  to  areas  supplied  by  the 
great  fifth  nerve  —  neuralgias,  headache,  migraine, 


*  For  a  full  account  of  the  anatomy  of  this  operation  see  "  The  Surgical 
Treatment  of  Facial  Neuralgia,"  by  J.  Hutchinson,  jun.    London,  1905. 


vn]  THE    PAROTID   GLAND  133 

etc. — it  is  necessary  to  realize  some  of  the  central 
connexions  of  the  sensory  nucleus  in  which  its 
afferent  fibres  terminate.  That  centre  extends  (see 
Fig.  33)  to  the  lower  part  of  the  medulla  oblongata, 
and  is  continuous  with  the  posterior  horn  of  the 
spinal  grey  matter,  in  which  the  sensory  fibres 
of  the  occipital  and  other  cervical  nerves  end. 
Near  by  is  the  sensory  nucleus  of  the  vagus.  Dis- 
turbances of  the  vagal  centres  can  overflow  and 
affect  the  sensory  nuclei  of  the  fifth,  the  pain 
being  usually  referred  to  the  distribution  of  that 
nerve  to  the  dura  mater.  Each  division  of  the 
fifth  nerve  sends  a  branch  to  the  dura  mater. 

Malar  bone.—  Such  is  the  firmness  of  this 
bone,  and  so  direct  is  its  connexion  with  the  skull, 
that  violent  blows  upon  it  are  very  apt  to  be  asso- 
ciated with  concussion.  Resting  as  it  does  upon 
comparatively  slender  bones,  it  is  very  rare  for  the 
malar  bone  to  be  broken  alone.  It  may,  indeed,  be 
driven  into  the  superior  maxillary  bone,  fracturing 
that  structure  extensively,  without  being  itself  in 
any  way  damaged.  A  fracture  of  the  malar  bone 
may  lead  to  an  orbital  ecchymosis,  precisely  like 
that  which  often  attends  a  fracture  of  the  skull 
base. 

2.   THE  PAROTID  REGION 

The    deep    part    of    the    parotid     gland    is 

lodged  in  a  definite  space  behind  the  ramus  of 
the  lower  jaw  (Fig.  34).  This  space  is  increased 
in  size  when  the  head  is  extended,  and  when 
the  inferior  maxilla  is  moved  forwards,  as  in 
protruding  the  chin.  In  the  latter  movement 
the  increase  in  the  antero-posterior  direction  is 
equal  to  about  f  of  an  inch.  It  is  diminished  when 
the  head  is  flexed.  When  the  mouth  is  widely 
opened  the  space  is  diminished  below,  while  it  is 
increased  above  by  the  gliding  forwards  of  the 
condyle.  These  facts  should  be  borne  in  mind  in 
operating  upon  and  in  exploring  the  parotid  space. 
It  will  be  found  also  that  in  inflammation  of  the 
parotid  much  pain  is  produced  by  all  those  move- 


134 


THE    HEAD    AND    NECK 


[CHAP. 


ments  that  tend  to  narrow  the  space  occupied  by 
the  gland.  The  obliquity  of  the  ramus  of  the  jaw 
in  infancy  and  old  age  causes  the  lower  part  of  the 
space  to  be,  in  the  former  instance  relatively  and 

in  the  latter  instance 
actually,  larger  than  it 
is  in  the  adult.  The 
larger  part  of  the  gland 
is  superficial  and  ex- 
tends over  the  masseter 
muscle. 

The  gland  is  closely 
invested  by  a  fascia 
derived  from  the  cer- 
vical fascia.  The  super- 
ficial layer  of  the 
parotid  fascia  is  very 
dense,  continuous  be- 
hind with  the  fibrous 


Fig.  34.  — Horizontal  section 
through  one  side  of  the  face 
and  neck  just  above  the 
level  of  the  lower  teeth. 
(Braune.) 

a,  Facial  artery  ;  b,  facial  vein  :  <\ 
gustatory  nerve ;  d,  inferior 
dental  nerve  and  artery  lying 
internally  to  the  ascending 
ramus  of  jaw  ;  t,  styloid  pro- 
cess :  /.  internal  carotid  artery  ; 
(h  internal  jugular  vein,  with 
the  vagus,  spinal  accessory, 
and  hypoglossal  nerves  to  its 
inner  side  ;  h,  vertebral  artery. 
Externally  to  the  ascending 
ramus  is  shown  the  masseter  : 
internally  to  it  the  internal 
pterygoid ;  internally  to  the 
last-named  muscle,  the  supe- 
rior constrictor  and  tonsil. 

sheath  of  the  sterno-mastoid,  and  in  front  with 
that  of  the  masseter.  Above  it  is  attached  to 
the  zygoma,  while  below  it  joins  the  deep  layer. 
The  deep  layer  is  slender,  is  attached  to  the 
etyloid  process,  forms  the  stylo-maxillary  liga- 


vn]  THE    PAROTID   GLAND  135 

ment,  and  is  connected  with  the  sheaths  of  the 
pterygoid  muscles  and  the  pterygoid  process.  The 
gland  is,  therefore,  encased  in  a  distinct  sac  of 
fascia,  which  is  entirely  closed  below,  but  is 
open  above.  Between  the  anterior  edge  of  the 
styloid  process  and  the  posterior  border  of  the 
internal  pterygoid  muscle  there  is  a  gap  in 
the  fascia,  through  which  the  parotid  space  com- 
municates with  the  connective  tissue  about  the 
pharynx.  It  is  well  known  that  in  postpharyngeal 
abscesses  there  is  very  usually  a  parotid  swelling, 
and  in  several  instances  the  pus,  or  at  least  some 
portion  of  it,  has  been  evacuated  in  the  parotid 
region.  In  these  cases  the  matter  most  probably 
extends  from  the  pharyngeal  to  the  parotid  region 
through  the  gap  just  described.  From  the  disposi- 
tion of  the  fascia  it  follows  that  very  great  resist- 
ance is  offered  to  the  progress  of  a  parotid  abscess 
directly  outwards  through  the  skin.  The  abscess 
often  advances  upwards  to  the  temporal,  or  zygo- 
matic  fossae,  in  the  direction  of  least  resistance,  al- 
though progress  in  that  line  is  resisted  by  gravity. 
It  frequently  makes  its  way  towards  the  buccal 
cavity  or  pharynx,  or  it  may  break  through  the 
lower  limits  of  the  fascia  and  reach  the  neck.  It 
must  be  borne  in  mind  that  the  gland  is  in  direct 
contact  with  the  cartilaginous  meatus,  with  the 
ramus  of  the  jaw  and  other  bony  parts,  and  is 
closely  related  to  the  temporo-maxillary  joint. 
Thus,  a  parotid  abscess  has  burst  into  the  meatus, 
has  led  to  periostitis  of  the  bones  adjacent  to  it, 
and  has  incited  inflammation  in  the  joint  of  the 
lower  jaw. 

In  several  cases  reported  by  Virchow  the  pus 
appears  to  have  found  its  way  into  the  skull  along 
branches  of  the  fifth  nerve,  for  the  environs  of  the 
semilunar  ganglion  were  found  infiltrated  with 
pus.  The  auriculo-temporal  and  great  auricular 
nerves  supply  the  gland  with  sensation,  and  the 
presence  of  these  nerves,  together  with  the  unyield- 
ing character  of  the  parotid  fascia,  serves  to 
explain  the  great  pain  felt  in  rapidly  growing 


136  THE    HEAD    AND    NECK  [CHAP. 

tumours  and  acute  inflammation  of  the  gland. 
The  pain  is  often  very  distinctly  referred  along 
the  course  of  the  auriculo-temporal  nerve.  Thus, 
a  patient  with  parotid  growth  under  my  (F.  T.'s) 
care  had  pain  in  those  parts  of  the  pinna  and 
temple  supplied  by  the  nerve,  pain  deep  in  the 
meatus,  at  a  spot  that  would  correspond  to  the 
entrance  of  the  ineatal  branch  of  the  nerve,  and 
pain  in  the  joint  of  the  lower  jaw,  which  is 
supplied  by  the  auriculo-temporal. 

The  most  important  structures  in  the  gland 
are  the  external  carotid  artery,  with  its  two 
terminal  branches,  and  the  facial  nerve.  The 
external  carotid  artery,  as  Tillaux  has  pointed 
out,  is  behind  the  ramus  of  the  jaw,  as  high 
up  as  the  junction  of  the  inferior  with  the 
middle  third  of  its  posterior  border.  It  then 
enters  the  parotid  gland,  and,  passing  a  little 
backwards  and  outwards,  comes  nearer  to  the 
surface,  and  at  the  level  of  the  condyle  of  the  jaw 
breaks  into  its  two  terminal  branches.  The  artery, 
therefore,  does  not  enter  the  gland  at  its  inferior 
border,  and  is  not  in  actual  relation  with  the 
parotid  space  at  its  lowest  part.  The  vessel,  more- 
over, is  not  parallel  with  the  edge  of  the  ramus, 
but  passes  through  the  parotid  gland  with  some 
obliquity. 

At  its  point  of  exit  from  the  base  of  the 
skull  by  the  stylo-mastoid  foramen,  the  facial 
nerve  lies  1  inch  deep  to  the  mid-point  of  the 
anterior  border  of  the  mastoid  process;  a  line 
drawn  horizontally  forwards  from  that  point  to 
the  posterior  border  of  the  ascending  ramus  of  the 
mandible  marks  the  position  of  the  main  trunk  of 
the  nerve  (Fig.  35).  Within  the  gland,  where  ^the 
nerve  divides  into  its  temporo-facial  and  cervico- 
facial  divisions,  it  is  superficial  to  the  external 
carotid  artery  and  the  temporo-maxillary  vein. 
The  nerve  has  been  stretched  close  to  its  point  of 
exit  from  the  stylo-mastoid  foramen  for  the  relief 
of  facial  tic.  It  is  best  found  at  a  spot  about  $  of 
an  inch  in  front  of  the  centre  of  the  anterior 


vn]        SECTION   OF  THE   FACIAL  NERVE        137 

border  of  the  mastoid  process.  It  will  be  found 
above  the  posterior  ^  belly  of  the  digastric,  which 
serves  as  a  guide  to  it  in  the  depth  of  the  wound. 

Section  of  the  facial  nerve  causes  paralysis 
of  the  buccinator  and  of  all  the  muscles  of  ex- 
pression, the  mouth  being  pulled  towards  the 
sound  side  and  the  eye  remaining  unclosed.  It 
also  contains  certain  afferent  fibres  which  are 


SUP  TEMP.AR.T. 

AUDITOR/ /I  EATUS 

*X   ART 
S.TYLOI  D   PtlOC. 

TACIAL  /leave 

S  PI  AIAL  ACCESSORY  /I. 
POCLOSSAL  N. 
N  SON'S  DUCT 
CAKOTID  Aar 


Fig.  35.— Surface  markings  of  the  facial,  spinal  accessory, 
and  hypoglossal  nerves. 

A,  Mid-point  of  anterior  border  of  mastoid  process  ;  B,  point  on 
anterior  border  of  sterno-mastoid,  1  inch  below  mastoid  process  ; 
c,  mid-point  of  posterior  border  of  sterno-mastoid.  Above  B 
the  transverse  process  of  the  atlas  is  indicated. 

sensitive  to  deep  pressure.  To  restore  mobility 
to  the  face  in  cases  of  palsy,  surgeons  have, 
in  a  number  of  instances,  sutured  the  facial 
to  the  trunk  of  a  neighbouring  nerve — the 
trunks  selected  being  the  spinal  accessory  and 
hypoglossal  (Fig.  35).  In  tho  one  case  the  muscles 
of  expression  are  thrown  into  action  when  the 
trapezius  and  sterno-mastoid  are  used;  in  the 

p* 


138  THE    HEAD    AND    NECK  [CHAP. 

other  when  the  tongue  is  moved.  In  course  of  time 
the  patient  may  become  able  to  dissociate  these 
inconveniently  combined  movements.  At  its  point 
of  exit  the  facial  nerve  gives  off  its  posterior 
auricular  branch  to  the  muscles  of  the  ear  and 
twigs  to  the  posterior  belly  of  the  digastric  and 
stylo-hyoid  muscles. 

Tumours  of  the  parotid  are  very  apt  to  contain 
cartilaginous  tissue.  It  is  well  known  that,  after 
mumps,  metastatic  abscesses  are  quite  common  in 
the  testis.  It  is  significant  in  this  connexion 
that  the  testis  is  one  of  the  few  parts  of  the 
body,  apart  from  bone,  where  cartilaginous  matter 
forms  a  frequent  constituent  of  the  neoplasms 
of  the  part.  Mr.  Paget  has  pointed  out  that 
inflammation  of  the  parotid  is  peculiarly  frequent 
after  injuries  and  diseases  of  the  abdomen  and 
pelvis.  It  occurs  also  very  often  as  a  sequela 
of  some  specific  fevers,  but  more  especially  after 
typhoid.  The  anatomical  or  physiological  basis 
of  this  connexion  has  not  been  made  out. 

Many  lymphatic  glands  are  placed  upon  the 
surface  and  in  the  substance  of  the  parotid  gland. 
They  receive  lymph  from  the  frontal  and  parietal 
regions  of  the  scalp,  from  the  orbit,  the  posterior 
part  of  the  nasal  fossae,  the  upper  jaw,  and  the 
hinder  and  upper  part  of  the  pharynx.  When 
enlarged,  these  glands  may  form  one  species  of 
"parotid  tumour." 

The  parotid  (Steiisoii's)  duet  (Fig.  35)  is 
about  2^  inches  long,  and  has  a  diameter  of  |-  of  an 
inch,  its  orifice  being  the  narrowest  part.  At  the  an- 
terior border  of  the  masseter  muscle  the  duct  bends 
suddenly  inwards  to  pierce  the  buccinator  muscle. 
The  bend  is  so  abrupt  that  the  buccal  segment  of 
the  duct  may  be  almost  at  right  angles  with  the 
masseteric.  This  bend  should  be  taken  into  con- 
sideration in  passing  a  probe  along  the  duct  from 
the  mouth.  The  duct  opens  on  the  summit  of  a 
papilla  placed  on  a  level  with  the  second  upper 
molar  tooth.  The  course  of  the  duct  across  the 
masseter  is  represented  by  a  line  drawn  from  the 


vn]  THE  MAXILLA  139 

lower  margin  of  the  concha  to  a  point  midway 
between  the  ala  of  the  nose  and  the  red  margin  of 
the  lip.  It  lies  about  a  finger-breadth  below  the 
zygoma,  having  the  transverse  facial  artery  above 
it  and  the  infraorbital  branches  of  the  facial  nerve 
below.  The  duct  has  been  ruptured  subcufcane- 
ously,  leading  to  extravasations  of  saliva.  Wounds 
of  the  duct  are  apt  to  lead  to  salivary  fistulse. 
At  least  one-half  of  the  buccal  part  of  the  duct 
is  embedded  in  the  substance  of  the  buccinator 
muscle.  A  salivary  fistula  over  the  masseter  may 
involve  the  parotid  gland  itself,  or  that  part  of 
it  known  as  the  socia  parotidis.  Inflammatory 
conditions  may  spread  to  the  parotid  from  the 
mouth  along  the  duct. 

3.    THE  UPPER  AND  LOWER  JAWS,  AND  PARTS 
CONNECTED  WITH  THEM 

Maxilla  (for  maxillary  sinus,  nee  p.  119; 
for  hard  palate,  see  p.  162). — This  bone,  on  ac- 
count of  its  fragility  and  the  manner  in  which 
it  is  hollowed  out,  is  very  readily  fractured. 
As  the  bone  is  very  vascular,  serious  injuries, 
involving  great  loss  of  substance,  are  often 
wonderfully  repaired.  Its  hollowness,  and  the 
cavities  that  it  helps  to  bound,  render  it  pos- 
sible for  large  foreign  bodies  to  be  retained 
in  the  deeper  parts  of  the  face.  Thus,  Long- 
more  reports  "the  case  of  Lieutenant  Fretz,  of 
the  Ceylon  Rifles,  who  was  able  to  do  his  mili- 
tary duties  for  nearly  eight  years  with  the  breech 
and  screw  of  a  burst  musket  lodged  in  the  nares, 
part  of  the  tail-pin  and  screw  protruding  through 
the  hard  palate  into  the^  mouth."  The  bone  may 
undergo  extensive  necrosis,  as  in  workers  in  match 
factories  exposed  to  the  fumes  of  white  phos- 
phorus. In  one  case  (.Medical  Times  and  Gazette, 
1862)  of  necrosis  following  measles  the  mischief 
was  limited  to  the  premaxillary,  or  incisive,  bone. 

The  periosteum  of  the  maxilla  is,  like  the 
pericranium,  not  disposed  to  form  new  bone.  In 


HO  THE    HEAD    AND    NEGK  [CHAP. 

ordinary  cases  of  necrosis  of  the  upper  jaw  no  re- 
production of  bone  takes  place,  the  gap  being  left 
permanent.  In  the  mandible  abundant  new  bone 
is  produced  by  the  periosteum,  and  extensive 
losses  may  be  repaired.  It  is  remarkable,  however, 
that  in  course  of  years  this  new  bone  is  liable  to 
be  very  extensively  reabsorbed. 

Excision  of  the  maxilla, — The  entire  bone  has 
been  frequently  removed  when  the  seat  of  an 
extensive  tumour,  and  under  certain  other  con- 
ditions. The  bony  connexions  to  be  divided  in 
the  operation  are  the  following  (see  Fig.  26,  p.  107, 
and  Fig.  30,  p.  126)  :  (1)  The  connexion  with  the 
malar  bone  at  the  outer  side  of  the  orbit;  (2) 
the  connexion  of  the  nasal  (frontal)  process  with 
the  frontal,  nasal,  and  lacrimal  bones;  (3)  the 
connexions  of  the  orbital  plate 'with  the  ethmoid 
and  palate  (the  orbital  plate  is  often  left  behind, 
or  is  cut  through  near  the  orbital  margin) ; 
(4)  the  connexion  with  the  opposite  bone  and 
the  palate  in  the  roof  of  the  mouth;  and  (5)  the 
connexion  behind  with  the  palate  bone,  and  the 
fibrous  attachments  to  the  pterygoid  processes.  In 
the  four  first-named  instances  the  separation  is 
effected  by^a  cutting  ^  instrument ;  in  the  last- 
named,  by  simply  twisting  out  the  bone. 

Soft  parts  divided:  These  may  be  considered 
under  three  heads  :  The  parts  cut  (1)  in  the  first 
incision ;  (2)  in  turning  back  the  flap ;  and  (3)  in 
separating  the  bone. 

(1)  The  following  are  the  parts  cut,  in  order 
from  above  downwards,  in  the  usual,  or  "median," 
incision,  an  incision  commencing  parallel  with  the 
lower  eyelid,  and  continued  down  the  side  of  the 
nose,  round  the  ala,  and  through  the  middle  of 
the  upper  lip  :  Skin,  superficial  fascia,  orbicularis 
oculi,  palpebral  branches  of  infraorbital  nerve  and 
artery,  part  of  the  levator  labii  superioris,  angular 
artery  and  vein,  lateral  nasal  artery  and  vein, 
nasal  branches  of  infraorbital  nerve,  compressor 
naris  (musculus  nasalis),  depressor  of  the  septum 
and  alse  of  the  nose,  attachment  of  nasal  cartilage 


vii]  THE   MANDIBLE  141 

to  bone,  orbicularis  oris,  superior  coronary  artery 
and  vein,  and  mucous  membrane  of  lip.  Various 
branches  of  the  facial  nerve  to  the  muscles  may 
be  cut.  (2)  In  turning  back  the  flap,  the  muscles 
above  named  will  be  dissected  up,  together  with 
the  internal  palpebral  ligament,  if  the  frontal 
process  is  removed  entire,  the  levator  anguli,  the 
buccinator,  a  few  fibres  of  the  masseter,  and,  on 
the  orbital  plate,  the  inferior  oblique  muscles.  The 
infraorbital  nerve  and  artery  will  be  cut  as  they 
leave  their  foramen.  In  the  flap  itself  will  be  the 
trunks  of  the  facial  artery  and  vein,  the  transverse 
facial  artery,  and  the  facial  part  of  the  facial  nerve. 
(3)  In  separating  the  frontal  process  the  lacrimal 
sac  and  infratrqchlear  nerve  will  be  damaged, 
and  the  naso-lacrimal  duct  and  external  branch  of 
the  nasal  nerve  cut  across.  In  separating  the  bones 
below,  the  coverings  of  the  hard  palate  are  divided, 
and  the  attachment  of  the  soft  palate  to  the 
palate  bone,  unless  the  removal  of  that  process 
can  be  avoided.  "  Any  attempt  to  dissect  off  and 
preserve  the  soft  covering  of  the  hard  palate  is 
futile"  (Heath).  Posteriorly,  the  trunk  of  the 
infraorbital  nerve  is  again  divided  (this  time  in 
front  of  the  spheno-palatine  ganglion),  together 
with  the  posterior  dental  and  infraorbital  arte- 
ries, and  some  branches  of  the  spheno-palatine 
artery.  The  deep  facial  vein  from  the  pterygoid 
plexus  will  probably  be  cut,  and,  lastly,  near 
the  palate  will  also  be  divided  the  large  palatine 
nerve  and  the  descending  palatine  artery. 

It  will  be  seen  that  no  large  artery  is  divided 
in  the  operation.  The  inferior  turbinated  bone 
(maxillo-turbinal)  comes  away,  of  course,  with 
the  maxilla. 

mandible. — This  bone  is  to  a  great  extent 
protected  from  fracture  by  its  horse-shoe  shape, 
which  gives  it  some  of  the  properties  of  a 
spring,  by  its  density  of  structure,  by  its^great 
mobility,  and  by  the  buffer-like  inter  articular 
cartilages  that  protect  its  attached  extremities. 
The  bone  is  usually  broken  by  direct  violence. 


142  THE    HEAD    AND    NECK  [CHAP. 

and  the  fracture  may  be  in  any  part.  The  sym- 
physis  is  rarely  broken,  on  account  of  its  great 
thickness.  The  ramus  is  protected  by  the  muscu- 
lar pads  that  envelop  its  two  sides,  and  the  coro- 
noid  process  is  still  more  out  of  the  risk  of  injury, 
owing  to  the  depth  at  which  it  is  placed  and  the 
protection  it  derives  from  the  zygoma.  The  weak- 
est part  of  the  bone  is  in  front,  where  its  strength 
is  diminished  by  the  mental  foramen  and  by  the 
large  socket  required  for  the  canine  tooth.  It  is 
about  this  part,  therefore,  that  fracture  is  the  most 
common.  The  bone  may  be  broken  near,  or  even 
through,  the  symphysis  by  indirect  violence,  as  by 
a  blow  or  crushing  force  that  tends  to  approximate 
the  two  rami.  Thus,  the  jaw  has  been  broken  near 
the  middle  line  by  a  blow  in  the  masseteric  region. 
The  amount  of  displacement  in  fractures  of  this 
bone  varies  greatly,  and  is  much  influenced  by  the 
nature  and  direction  of  the  force.  In  general 
terms,  it  may  be  said  that  when  the  body  of  the 
bone  is  broken  the  anterior  fragment  is  drawn 
backwards  and  downwards  by  the  jaw  depressors, 
the  digastric,  mylo-hyoid,  genio-hyoid,  and  genio- 
glossus;  while  the  hinder  fragment  is  drawn  up 
by  the  elevators  of  the  jaw,  the  masseter,  internal 
pterygoid,  and  temporal.  The  dense  muco-peri- 
osteum  covering  the  alveolar  part  of  the  mandible 
is  usually  also  torn  through,  and  thus  the  frac- 
tured surfaces  are  exposed  to  the  septic  condi- 
tions which  prevail  within  the  mouth.  It  must 
be  remembered  that  the  mylo-hyoid  muscle  will 
be  attached  to  both  fragments,  and  will  modify 
the  amount  of  displacement.  Fractures  of  the 
ramus  are  seldom  attended  with  much  displace- 
ment, muscular  tissue  being  nearly  equally  attached 
to  both  fragments. 

In  fractures  of  the  body  of  the  bone  the  dental 
nerve  often  marvellously  escapes  injury,  a  fact  that 
is  explained  by  the  supposition  that  tue  bones  are 
not  usually  sufficiently  displaced  to  tear  across  the 
nerve.  Weeks  after  the  accident,  however,  the 
nerve  has  become  so  compressed  by  the  developing 


vii]  MANDIBULAR  JOINT  143 

callus  as  to  have  its  function  destroyed.  One  or 
both  condyloid  processes  have  often  been  broken 
by  falls  or  blows  upon  the  chin. 

The  mamlilMilai*  (temporo-m axillary) joint 

is  supported  by  a  capsule  which  varies  greatly  in 
thickness  in  different  parts.  By  far  the  thickest 
part  of  the  capsule  is  the  external  part  (the 
temporo-mandibular  or  lateral  ligament).  The 
internal  part  is  next  in  thickness,  while  the 
anterior  and  posterior  portions  of  the  capsule 
are  thin,  especially  the  former,  which  is  very 
thin.  Thus,  when  this  joint  suppurates,  the  pus 
is  least  likely  to  escape  on  the  external  aspect  of 
the  articulation,  and  is  most  likely  to  find  an  exit 
through  the  anterior  part  of  the  capsule,  although 
this  part  is  to  a  great  extent  protected  by  the 
attachments  of  the  external  pterygoid  muscle. 
Immediately  behind  the  condyle  of  the  jaw  are 
the  bony  meatus  and,  a  little  to  the  inner  side, 
the  middle  ear.  In  violent  blows  upon  the  front 
of  the  jaw  these  structures  may  be  damaged, 
and  it  is  interesting  to  note  that  the  strongest 
ligament  of  the  joint  (the  external  lateral)  has 
a  direction  downwards  and  backwards,  so  as  im- 
mediately to  resist  any  movement  of  the  condyle 
towards  the  slender  wall  of  bone  that  bounds  the 
meatus  and  tympanum.  Were  it  not  for  this  liga- 
ment, a  blow  upon  the  chin  would  be  a  much  more 
serious  accident  than  it  is. 

The-  movements  of  this  joint  are  peculiar.  On 
opening  the  mouth  it  will  be  observed  that  the 
condyle  moves  forwards  and  downwards  upon  the 
articular  eminence,  while  the  angle  of  ^  the  jaw 
moves  in  a  backward  and  upward  direction.  The 
approximate  axis  of  the  movement  is  a  transverse 
line  drawn  between  the  inferior  dental  fora- 
mina; thus,  it  will  be  seen  that  the  inferior 
dental  nerves  (alveolar)  enter  the  mandible  at  the 
point  of  least  movement.  The  external  pterygoid 
muscles,  by  pulling  the  condyle  upon  the  articular 
eminence,  take  the  chief  part  in  opening  the 
mouth;  at  the  same  time  the  chin  is  depressed  by 


144  THE    HEAD    AND    NECK 

the  contraction  of  the  mylo-hyoid  and  digastric 
muscles. 

Dislocation. — This  joint  permits  of  only  one 
form  of  dislocation,  a  dislocation  forwards.  It  may 
be  unilateral  or  bilateral,  the  latter  being  the  more 
usual,  and  it  can  only  occur  when  the  mouth  hap- 
pens to  be  wide  open.  Indeed,  the  dislocation  is 
nearly  always  due  to  spasmodic  muscular  action 
when  the  mouth  is  open,  although  in  some  few  cases 
it  has  been  brought  about  by  indirect  violence,  as 
by  a  downward  blow  upon  the  lower  front  teeth, 
the  mouth  being  widely  opened.  It  has  occurred 
during  yawning,  violent  vomiting,  etc.  In  more 
than  one  case  the  accident  happened  while  a 
dentist  was  taking  a  cast  of  the  mouth.  Hamilton 
quotes  a  bilateral  dislocation  in  a  woman  during 
the  violent  gesticulations  incident  to  the  pursuit 
of  scolding  her  husband.  When  the  mouth  is 
widely  opened,  the  condyles,  together  with  the 
interarticular  fibre-cartilage,  glide  forward.  The 
fibro-cartilage  extends  as  far  as  the  anterior  edge 
of  the  eminentia  articularis,  which  is  coated  with 
cartilage  to  receive  it.  The  condyle  never  reaches 
quite  so  far  as  the  summit  of  that  eminence.  All 
parts  of  the  capsule  save  the  anterior  are  rendered 
tense.  The  coronoid  process  is  much  depressed. 
Now,  if  the  external  pterygoid  muscle  (the  muscle 
mainly  answerable  for  the  luxation)  contract  vigor- 
ously, the  condyle  is  soon  drawn  over  the  eminence 
into  the  zygpmatic  fossa,  the  interarticular  carti- 
lage remaining  behind.  On  reaching  its  new  posi- 
tion it  is  immediately  drawn  up  by  the  temporal, 
internal  pterygoid,  and  masseter  muscles,  and  is 
thereby  more  or  less  fixed.  A  specimen  in  the 
Mus£e  Dupuytren  shows  that  the  fixity  of  the  lux- 
ated jaw  may  sometimes  depend  upon  the  catch- 
ing of  the  apex  of  the  coronoid  process  against 
the  malar  bone. 

Subluxation  of  the  mandible  is  a  name  given 
to  a  slight  and  quite  incomplete  dislocation  of  the 
jaw  not  infrequently  met  with  in  delicate  women. 
It  is  due  to  a  displacement  of  the  interarticular 


vn]  EXCISION   OF   THE  MANDIBLE  145 

cartilage,  and  can  be  cured  by  exposing  the  car- 
tilage and  attaching  it  by  suture  to  the  fibrous 
structures  around  the  joint  (Annandale). 

Excision  of  the  mandible. — Considerable  por- 
tions of  the  lower  jaw  can  be  excised  through 
the  mouth  without  external  wound.  In  excising 
one  entire  half  of  the  maxilla,  a  cut  is  made 
vertically  through  the  lower  lip  down  to  the  point 
of  the  chin,  ana  is  then  continued  back  along  the 
inferior  border  of  the  jaw,  so  as  to  end  near  the 
lobule  of  the  ear,  after  having  been  carried  verti- 
cally upwards  in  the  line  of  the  posterior  border 
of  the  ramus.  The  soft  parts  divided  may  be  con- 
sidered under  three  heads  :  Those  concerned  (1)  in 
the  first  incision  ;  (2)  in  clearing  the  outer  surface 
of  the  bone;  (3)  in  clearing  the  inner  surface  of 
the  bone. 

1.  (a)  In  the  anterior  vertical  cut:    Skin,  etc., 
orbicularis    oris,    inferior    coronary    and    inferior 
labial  vessels,  branches  of  submental  artery,  leva- 
tor  menti,  mental  vessels  and  nerve,  some  radicles 
of  anterior  jugular  vein.    (6)   In  the  horizontal 
cut:   Skin,  etc.,  platysma,  branches  of  superficial 
cervical  nerve  (nervus  cutaneus  colli)  branches  of 
supramandibular    part    of    facial    nerve,    facial 
artery  and  vein  at  edge  of  masseter,   and  infra- 
mandibular    branch    of    facial    nerve    (not   neces- 
sarily  divided),      (c)    The   posterior   vertical   in- 
cision would  not  go  down  to  the  bone,  and  would 
merely  expose  the  surface  of  the  parotid   gland 
and  part  of  posterior  border  of  masseter  muscle. 

2.  In  clearing  the  outer  surface  the  ^  following 
parts  are  dissected  back  :  Levator  menti,  the  two 
depressor  muscles,   buccinator,   masseter  (crossed 
by  part  of  parotid  gland,  transverse  facial  vessels, 
facial  nerve,  and  Stenson's  duct),  masseteric  ves- 
sels and  nerve,  temporal  muscle. 

3.  In   clearing   the  inner   surface :    Digastric, 
genio-hyoid,  genio-glossus,  and  mylo-hyoid  muscles, 
a    few    fibres    of    superior    constrictor,    internal 
pterygoid  muscle,  inferior  dental  (alveolar)  artery 
and  nerve,  mylo-hyoid  vessels  and  nerve,  internal 


146  THE    HEAD    AND    NECK  [CHAP. 

lateral  ligament,  rest  of  insertion  of  temporal 
muscle,  mucous  membrane. 

Parts  in  risk  of  being  damaged. — The  facial 
nerve,  if  the  posterior  vertical  incision  be  carried 
too  high  up.  The  internal  maxillary  artery, 
temporo-maxillary  vein,  auriculo-temporal  nerve 
(structures  all  closely  related  to  the  jaw  condyle), 
external  carotid  artery,  lingual  nerve,  the  paro- 
tid, submandibular,  and  sublingual  glands.  After 
subperiosteal  resection  the  entire  bone  has  been 
reproduced. 

Deformities. — The  lower  jaw  may  be  entirely 
absent,  or  of  dwarfed  dimensions,  or  incompletely 
formed.  These  conditions  are  congenital,  and 
depend  upon  the  defective  development  of  the 
mandibular  or  first  visceral  arch,  out  of  which 
the  lower  jaw  is  formed  (Fig.  29,  p.  124).  They 
are  often  associated  with  branchial  fistulse,  super- 
numerary ears,  macrostoma,  and  like  congenital 
malformations. 

Nerves  of  the  jaws. — The  upper  teeth  are  sup- 
plied by  the  second  division  of  the  fifth,  the  lower 
by  the  third  division.  Some  remarkable  mani- 
festations of  reflex  action  have  followed  irritative 
lesions  of  the  dental  nerves.  Thus,  cases  of  stra- 
bismus, temporary  blindness,  and  wry-neck  have 
been  reported  as  due  to  the  irritation  of  carious 
teeth.  Hilton  gives  the  case  of  a  man  who  was 
much  troubled  by  a  carious  tooth  in  the  lower  jaw 
(supplied  by  the  third  division  of  the  fifth),  and 
who  developed  a  patch  of  grey  hair  over  the  region 
supplied  by  the  auriculo-temporal  nerve  (a  branch 
also  of  the  third  division).  The  roots  of  the  third 
lower  molar  are  in  close  proximity  to  the  dental 
(mandibular)  canal,  and  hence  the  nerve  may  be 
torn  if  this  tooth  is  roughly  extracted.  The  roots 
have  been  seen  actually  to  enclose  the  nerve. 

Caries  of  the  teeth  is  frequently  associated  with 
areas  of  hyperaesthesia  on  the  side  of  the  face  and 
neck.  The  explanation  of  the  reflection,  to  cer- 
tain areas  of  skin,  of  pain  set  up  by  dental  caries 
must  be  sought  for  in  a  close  association  of  the 


vii]  MUSCLES   OF  MASTICATION  147 

central  nerve  nuclei,  in  whrch  the  cutaneous  and 
dental  nerves  terminate  (see  Fig,  33,  p.  132). 
Disease  of  the  peridental  membrane  does  not  give 
rise  to  referred  pains  (Head). 

The  muscles  of  mastication  are  often  at- 
tacked by  spasm.  Nowhere  else  in  the  body  is 
a  group  of  muscles  opposed  by  so  weak  a  group 
of  opponents  as  in  the  mandibular  region.  The 
temporal,  masseter,  and  internal  pterygoid  give 
the  mandible  its  great  biting  and  grinding  power ; 
their  opponents,  which  depress  the  mandible — the 
external  pterygoid,  digastric,  mylo-hyoid,  genio- 
hyoid — are  able  to  afford  but  weak  resistance  to 
them.  Hence,  when  in  a  state  of  spasm,  they  at 
once  prevail  over  their  opponents.  When  the 
spasm  is  clonic,  chattering  of  the  teeth  is  pro- 
duced. When  the  spasm  is  tonic  the  mouth  is 
rigidly  closed,  and  the  condition  known  as  trismus, 
or  lockjaw,  is  produced.  Trismus  is  among  the 
first  symptoms  of  tetanus.  It  is  also  very  apt  to 
be  produced  by  irritation  of  any  of  the  sensory 
branches  of  the  third  division  of  the  fifth.  Thus, 
trismus  is  very  common  in  caries  of  the  lower 
teeth,  and  during  the  "cutting"  of  the  lower 
wisdom  tooth;  it  is  much  less  common  in  affec- 
tions of  the  upper  set  of  teeth.  If  the  motor 
root  of  the  third  division  of  the  fifth  nerve  be 
cut  in  excising  the  Gasserian  ganglion,  paralysis 
and  atrophy  overtake  the  muscles  of  mastication 
of  the  corresponding  side.  The  muscles  of  the 
sound  side,  however,  are  still  able  to  carry  on 
the  necessary  movements  of  the  jaw  concerned  in 
speech  and  mastication. 

Teeth. — As  a  test  of  age  the  following  periods 
for  the  eruption  of  teeth  are  given  by  Mr.  C, 
Tomes:  Temporary  teeth:  Lower  central  incisors, 
six  to  nine  months;  upper  incisors,  ten  months; 
lower  lateral  incisors  and  four  first  molars,  a  few 
months  later ;  then,  after  a  rest  of  four  or  five 
months,  the  canines ;  and,  lastly,  the  second 
molars ;  the  whole  being  in  place  by  the  end  of  the 
second  year.  Permanent  teeth:  First  molars,  sixth 


148  THE    HEAD    AND    NECK  [CHAP. 

or  seventh  year;  next  in  order  the  lower  central 
incisors,  then  the  upper  central  incisors,  and  a 
little  later  the  laterals,  the  eighth  year ;  first  bicus- 
pids, ninth  or  tenth  year;  second  bicuspids  and 
canines,  about  the  eleventh  year,  the  lower  preced- 
ing the  upper;  the  second  molars,  the  twelfth  or 
thirteenth  year;  the  wisdom  teeth,  18  to  25  or 
later. 

An  alveolar  abscess  is  formed  about  the  fang 
of  a  tooth.  In  the  case  of  single-fanged  teeth 
the  pus  may  escape  along  the  groove  of  the  fang. 


CQRONOlD     PffOC 
COMOVLE 


Fig.  36. — A,  Impaction  of  the  upper  third  molar  in  the 
maxilla.  B,  Impaction  of  the  lower  third  molar  in 
the  mandible. 

With  other  teeth  the  pus  tends  to  pierce  the 
alveolus.  If  the  point  of  the  fang  is  within  the 
reflection  of  the  mucous  membrane  from  the  gum 
to  the  cheek  the  abscess  will  break  into  the  mouth, 
but  if  the  point  of  the  fang  is  without  that  reflec- 
tion, or  if  the  pus  can  gravitate  without  the  line 
of  reflection,  then  the  pus  may  break  through  the 
cheek.  Alveolar  abscess  o>f  the  upper  incisors  and 
canines  never  breaks  through  the  cheek.  When 
connected  with  the  upper  molars  it  sometimes 
does;  an  abscess  forming  at  the  roots  of  the 
upper  molar  or  second  premolar  teeth  often  breaks 
into  the  maxillary  sinus.  The  roots  of  the  incisor, 


VH]  ALVEOLAR   ABSCESS  149 

canine,  and  first  premolar  teeth  are  more  remote 
from  the  sinus;  hence  abscesses  connected  with 
them  rarely  break  into  the  sinus.  When  con- 
nected with  any  of  the  lower  teeth  the  abscess 
may  find  its  way  through  the  skin  of  the  cheek. 

The  upper  wisdom  tooth  is  developed  in  the 
posterior  border  of  the  upper  jaw,  and  the-  lower 
wisdom  on  the  inner  aspect  of  the  ascending 
ramus.  They  may  fail  to  come  into  position,  or 
even  remain  deeply  buried.  (Fig.  36.)  They  may 
give  rise  to  deeply  seated  and  obscure  abscesses 
which  frequently  point  in  the  neck,  at  some 
distance  from  the  site  of  origin. 


CHAPTER   VIII 

THE  MOUTH,  TONGUE,  PALATE,  AND 
PHARYNX 

THE  MOUTH 

The  lips. — The  principal  tissues  composing  the 
lips  have  the  following  relation  to  one  another, 
proceeding  from  without  inwards:  (1)  Skin;  (2) 
superficial  fascia;  (3)  orbicularis  oris;  (4)  labial 
(coronary)  vessels;  (5)  mucous  glands,  and  (6) 
mucous  membrane.  The  free  border  of  the  lip  is 
very  sensitive,  many  of  the  nerves  having  end-bulbs 
closely  resembling  tactile  corpuscles.  The  upper  lip 
is  supplied  with  sensation  by  the  second  division 
of  the  fifth  nerve,  and  the  lower  lip  by  the  third 
division.  Over  these  labial  nerves  a  crop  of  herpes 
often  appears  (herpes  labialis).  The  free  border 
of  the  lower  lip  is  more  frequently  the  seat  of 
epithelioma  than  is  any  other  part  of  the  body ;  its 
lymphatic  vessels  pass  to  the  submental  and  sub- 
mandibular  lymphatic  glands  (Fig.  50,  p.  207).  The 
lips  contain  much  connective  tissue,  and  may  swell 
considerably  when  inflamed,  or  cedematous.  They 
are  very  mobile,  and  are  entirely  free  for  a 
considerable  extent  from  bony  attachment  of  any 
kind.  It  follows  that  destructive  inflammations  of 
the  lips,  and  such  losses  of  substance  as  accom- 
pany severe  burns,  produce  much  contraction  and 
deformity  of  the  ^  mouth.  Contracting  cicatrices, 
also,  in  the  vicinity  of  the  mouth  are  apt  to  drag 
upon  the  lips,  everting  them  or  producing  kindred 
distortions.  It  is  fortunate  that  the  laxity  of  the 
tissues  around  the  mouth,  and  the  general  vascu- 
150 


LIPS   AND   BUCCAL  CAVITY  151 

larity  of  the  part,  greatly  favour  the  success  of  the 
many  plastic  operations  performed  to  relieve  these 
deformities. 

The  lips  are  very  vascular,  and  are  often  the 
seat  of  nsevi  and  other  vascular  tumours.  The 
labial  arteries  are  of  large  size,  and  their  pulsa- 
tions can  generally  be  felt  when  the  lip  is 
pinched  up.  These  vessels  run  beneath  the  orbi- 
cularis  oris  muscle,  and  are  consequently  nearer 
to  the  mucous  membrane  than  they  are  to  the  skin. 
When  the  inner  surface  of  the  lip  is  cut  against 
the  teeth,  as  the  result  of  a  blow,  these  arteries 
are  very  apt  to  be  wounded.  As  such  wounds  are 
concealed  from  view,  the  consequent  haemorrhage 
has  sometimes  given  rise  to  an  erroneous  diag- 
nosis. Thus,  Erichsen  quotes  the  case  of  a  drunken 
man,  the  subject  of  such  a  wound,  who,  having 
swallowed,  and  then  vomited,  the  blood  escaping 
from  a  labial  artery,  was  for  a  while  supposed 
to  be  suffering  from  an  internal  injury.  As  the 
anastomoses  between  the  arteries  of  the  lip  are 
very  free,  it  is  usually  necessary  to  tie  both  ends 
of  the  vessel  when  it  has  been  cut  across. 

The  mucous  glands  in  the  submucous  tissue  are 
large  and  numerous.  From  closure  of  the  ducts 
of  these  glands,  and  their  subsequent  distension, 
result  the  "  mucous  cysts "  that  are  so  common 
about  the  lips.  "  Hare-lip "  is  noticed  below  in 
connexion  with  the  subject  of  cleft  palate. 

Buccal  cavity.— The  following  points  may  be 
noticed  in  the  examination  of  the  interior  of  the 
mouth :  In  the  floor  of  the  mouth,  on  either  side 
of  the  frenum  linguae,  can  be  observed  the  sub- 
lingual  papillae  with  the  openings  of  Wharton's 
ducts.  The  duct  of  Bartholin  (one  of  the  ducts 
of  the  sublingual  gland)  runs  along  the  last  part 
of  the  submandibular  (Wharton's)  duct,  and  opens 
either  with  it  or  very  near  it.  This  duct  is  singu- 
larly indistensible,  and  hence  is  partly  explained 
the  intense  pain  usually  observed  when  it  becomes 
obstructed  by  a  calculus.  The  proximity  of  this 
duct  to  the  lingual  nerve  may  serve  also  to  account 


152 


THE    HEAD    AND    NECK 


[CHAP. 


for  the  pain  in  some  cases.  The  submandibular 
gland  can  be  made  out  through  the  mucous  mem- 
brane at  a  point  a  little  in  front  of  the  angle 
of  the  jaw,  especially  when  the  gland  is  pressed 
up  from  the  outside.  On  the  floor  of  the  mouth, 
between  the  alveolus  and  the  anterior  part  of  the 
tongue,  is  a  well-marked  ridge  of  mucous  mem- 
brane, directed  obliquely  forwards  and  inwards  to 
the  sublingual  papilla  near  the  frenum.  It  indi- 
cates the  position  of  the  sublingual  gland  (Fig. 
37),  and  also,  so  far  as  it  goes,  the  line  of  the 
submandibular  duct  and  the  lingual  nerve.  These 


Cenio  /wo  GLOSS 

CEAIIO-rtYOlO 


Su«>  UAGU*ll» 

I/HM.IHCUALI& 
/IYO-CLOSMJS 

Ll«CUALApTEBV 
SuBUNCUftl Ci- 


Fig.  37. — Section  across  tongue  and  mandible  to  show  the 
position   of  the   sublingual  gland   and    lingual  artery. 

(After  Poiricr.) 

structures,  with  the  sublingual  artery,  lie  beneath 
the  mucous°~membrane  between  the  gland  and  the 
side  of  the  tongue.  The  ducts  of  the  sublingual 
gland,  some  ten  to  twenty  in  number,  open  into 
the  mouth  along  the  ridge  of  mucous  membrane 
just  referred  to.  Ranula,  a  cystic  tumour  filled 
with  mucous  contents,  is  often  met  with  over 
the  site  of  the  sublingual  gland,  and  is  due  to 
the  dilatation  of  a  duct  which  has  become  ob- 
structed, or  to  an  occluded  mucous  follicle.  The 
mucous  membrane  of  the  floor  of  the  mouth,  as  it 
passes  forwards  to  bo  reflected  on  to  the  gums,  is 
attached  near  to  the  upper  border  of  the  jaw  (Fig. 
37).  Here  also  are  situated  some  mucous  glands 


vm]  THE   MOUTH  153 

which  may  become  cystic.  The  genio-glossus  is 
attached  near  the  lower  border.  Between  these 
two  parts  (the  mucous  membrane  and  the  muscle) 
there  is,  according  to  Tillaux,  a  small  space  lined 
with  squamous  epithelium.  To  this  cavity  the 
name  of  the  sub-lingual  bursa  is  given.  It  is 
constricted  is  its  centre  by  the  frenum  linguae, 
and  is  said  to  be  the  seat  of  mischief  in  "acute 
ranula." 

When  the  mouth  is  widely  opened  the  pterygo- 
mandibular  ligament  can  be  readily  seen  and  felt 
beneath  the  mucous  membrane.  It  appears  as  a  pro- 
minent fold  running  obliquely  downwards  behind 
the  last  molar  teeth.  A  little  below'  and  in  front 
of  the  attachment  of  this  ligament  to  the  lower 
jaw,  the  lingual  nerve  can  be  felt  as  it  lies  close 
to ^ the  bone  just  below  the  last  molar.  At  this 
point  it  may  be  divided,  or  reached  by  the  needle 
of  a  syringe.  This  nerve,  as  it  lies  against  the 
bone,  has  been  crushed  by  the  slipping  of  the 
forceps  in  clumsy  extraction  of  the  lower  molar 
teeth. 

The  coronoid  process  of  the  lower  jaw  can  be 
easily  felt  through  the  mouth,  and  is  especially 
distinct  when  that  bone  is  dislocated.  It  may  be 
noted  that  a  fair  space  may  exist  between  the 
last  molar  tooth  and  the  ramus  of  the  mandible, 
through  which  a  patient  may  be  fed  by  a  tube  in 
cases  of  trismus  or  ankylosis  of  the  jaw. 

Congenital  dermoid  and  thyroid  cysts  are  some- 
times found  in  the  floor  of  the  mouth  between 
the  tongue  and  the  lower  jaw.  Such  cysts  are 
supposed  to  be  due  to  imperfect  closure  of  the 
first  visceral  or  postmandibular  cleft,  or  to  an 
aberrant  bud  of  the  median  thyroid  outgrowth. 

The  gums  are  dense,  firm,  and  very  vascular. 
In  the  bleeding  that  follows  the  extraction  of 
teeth  much  of  the  blood  is  supplied  by  them.  The 
gums  are  particularly  affected  in  mercurial  poison- 
ing, and  are  also  especially  involved  in  scurvy. 
In  chronic  lead-poisoning  a  blue  line  often  appears 
along  their  margins.  This  is  due  to  a  deposit  of 


154  THE    HEAD    AND    NEGK  [CHAP. 

lead  sulphide  in  the  gum  tissues,  which  is  thus 
derived  :  Food  debris  collected  about  the  teeth  in 
decomposing  produces  hydrogen  sulphide,  which, 
acting  upon  the  lead  circulating  in  the  blood,  pro- 
duces the  deposit.  The  blue  line,  therefore,  is  said 
not  to  occur  in  those  who  keep  the  teeth  clean. 

THE  TONGUE 

On  the  under  surface  of  the  tongue,  less  than 
£  an  inch  from  the  frenum,  the  end  of  the 
ranine  (comitans  hypoglossi)  vein  can  be  seen 
beneath  the  mucous  membrane.  Two  elevated  and 
fringed  lines  of  mucous  membrane  may  be  seen 
on  the  under  surface  of  the  organ,  converging 
towards  its  tip.  They  indicate  the  position  of 
the  ranine  (deep  lingual)  artery,  which  is  more 
deeply  placed  than  the  vein,  close  to  which  it 
lies.  It  is  extremely  rare  for  the  tongue  to  be 
the  seat  of  congenital  defects.  The  tip  may 
be  irregularly  cleft  or  show  glandular  polypi, 
probably  derived  from  the  glands  normally  found 
beneath  the  tip  of  the  tongue.  Fournier  gives 
a  case  where  the  tongue  was  so  much  longer  than 
usual  that  the  chest  could  be  touched  with  its 
tip  while  the  head  was  held  erect. 

In  rare  cases  the  fremini  linguae  may  be 
abnormally  short,  constituting  the  condition  known 
as  "  tongue-tie,"  which  is  really  a  very  uncommon 
affection.  The  genio-glossus,  the  chief  muscle  of 
the  f  tongue,  and  the  genio-hyoid  arise  from  the 
genial  (mental)  tubercles  of  the  symphysis.  The 
tongue  is  kept  from  falling  backwards  by  its 
attachments  to  the  symphysis;  if  these  attach- 
ments were  cut,  the  tongue  could  be  inverted  and 
swallowed.  In  complete  anaesthesia,  as  in  that 
produced  by  chloroform,  when  all  the  muscular 
attachments  of  the  tongue  are  relaxed,  the  organ 
is  apt  to  fall  back  and  to  press  down  the 
epiglottis,  so  causing  suffocation. 

The  tongue  is  firm  and  dense,  but  contains, 
nevertheless,  a  sufficient  amount  of  connective 
tissue  to  cause  it  to  swell  greatly  when  inflamed. 


vm]        LINGUAL  VESSELS   AND  NERVES         155 

The  surface  epithelium  is  thick,  and  in  chronic 
superficial  inflammation  of  the  organ  it  often  be- 
comes heaped  up,  forming  dense  opaque  layers— 
ichthyosis  linguae,  plaques  des  fumeurs,  leucoma, 
etc.  From  the  mucous  glands,  situated  chiefly  be- 
neath the  mucous  membrane  near  the  base  of  the 
tongue,  the  mucous  cysts  are  developed  that  are 
sometimes  met  with  in  this  part. 

The  tongue  is  very  vascular,  and  is  in  conse- 
quence often  the  seat  of  nsevoid  growths.  Its  main 
supply  is  from  the  lingual  artery*  This  vessel 
approaches  the  organ  from  the  under  surface, 
and,  as  cancer  usually  shows  a  tendency  to  spread 
towards  the  best  blood  supply,  it  is  to  be  noticed 
that  carcinoma  of  the  tongue  nearly  always  tends 
to  spread  towards  the  deep  attachment  of  the 
member.  At  the  same  time  it  must  be  observed 
that  the  main  lymphatics  follow  the  same  course 
as  the  main  blood-vessels;  cancer  in  spreading 
tends  also  to  follow  the  lymph-stream.  The 
vascularity  of  the  tongue  is  the  great  bar  to  its 
easy  removal,  haemorrhage  being  the  complication 
most  to  be  dreaded  in  such  operations. 

The  toiigiie  is  well  supplied  with  nerves. 
which  endue  it  not  only  with  the  special  sense  of 
taste,  but  also  with  common  sensation.  According 
to  Weber's  experiments,  tactile  sensibility  is  more 
acute  on  the  tip  of  the  tongue  than  it  is  on  any 
part  of  the  surface  of  the  body.  It  should  be  borne 
in  mind  that  the  lingual  nerve,  in  ^  which  the 
chorda  tympani  is  incorporated,  supplies  the  fore 
part  and  sides  of  the  tongue  for  two-thirds  of 
its  surface,  while  the  glosso-pharyngeal  nerve 
supplies  the  mucous  membrane  at  its  base,  and 
especially  the  papillae  vallatse.  After  excision  of 
the  semilunar  ganglion,  taste  is  unaffected  because 
the  fibres  subserving  that  sense  reach  the  lingual 
nerve  in  the  chorda  tympani.  The  latter  nerve 
must  also  convey  touch  fibres,  for  after  excision 
of  the  semdlunar  ganglion  a  certain  sensibility  to 
touch  is  still  retained  by  the  anterior  two-thirds 
of  ihe  tongue,  although  sensibility  to  pain  is 


156 


THE    HEAD    AND    NEOK 


[CHAP. 


completely  lost.  In  painful  affections,  situated 
in  the  area  supplied  by  the  lingual  nerve,  the 
patient  is  often  troubled  with  severe  pains  deep 
in  the  region  of  the  meatus  of  the  ear,  and  an 
area  of  skin  from  the  ear  along  the  lower  border 
of  the  jaw  may  be  tender  (Head).  The  anterior 
two-thirds  of  the  tongue  are  a  derivative  of  the 
mandibular  arch,  which  also  forms  the  anterior 


DORSAL  PLEXUS 


UP.    DEEP 

CERV.  GLANDS 


SUBLINQ.  GLAND 


SUBMENTAL 
MYLO-HYOID 

SUBMAX. 


CAROTID  ART. 


Fig.  38.— Lymphatics  of  the  tongue.     (After  Poirier.) 

boundary  of  the  meatus.  Hence  the  nerve  supply  of 
the  anterior  part  of  the  tongue  from  the  third  divi- 
sion of  the  fifth  nerve  and  the  reference  of  pain  to 
its  cutaneous  termination.  The  posterior  third  of 
the  tongue  is  derived  from  the  second  (hyoid)  and 
third  visceral  arches  and  is  associated  with  tender 
areas  in  the  skin  over  the  larynx  (Head).  Spas- 
modic contraction  of  the  masticatory  muscles  is 
sometimes  found  to  accompany  painful  lingual  ul- 
cers when  involving  the  region  of  the  gustatory 


VIH]  LINGUAL    LYMPHATICS  157 

nerve.  There  would  seem  to  be  little  connexion 
between  an  abscess  over  the  occipital  region  and 
wasting  of  one  half  of  the  tongue.  But  Sir  James 
Paget  reports  the  following  case  : 

"A  man  received  an  injury  to  the  back  of  his  head  that 
was  apparently  not  severe.  In  time  the  right  half  of  the 
tongue  began  to  waste,  and  continued  to  waste  until  it  was 
less  than  half  the  size  of  the  unaltered  side.  An  abscess 
formed  over  the  occiput,  from  which  fragments  of  the  lower 
part  of  the  occipital  bone  were  removed.  After  the  removal 
of  all  the  dead  bone  the  tongue  began  to  recover,  and  in  one 
month  had  nearly  regained  its  normal  aspect." 

Here  the  atrophy  was  due  to  wasting  of  the  lin- 
gual muscles  produced  by  pressure  upon  the  hypo- 
glossal  nerve,  which  leaves  the  skull  through  the 
anterior  condyloid  foramen  in  the  occipital  bone. 
The  case  illustrates  the  importance  of  remember- 
ing even  small  foramina,  and  the  structures  they 
transmit. 

The  tongue  contains  much  lymphoid  tissue,  a 
considerable  part  of  which  (the  lingual  tonsil)  is 
massed  under  the  mucous  membrane  at  the  pos- 
terior part  of  the  organ.  Hypertrophy  of  this  tissue 
may  lead  to  troublesome  symptoms  by  irritating 
the  sensitive  epiglottis.  The  lingual  and  pharyn- 
geal  adenoid  tissue,  and  the  tonsils  proper,  form 
a  complete  ring  of  lymphoid  tissue  round  the 
isthmus  of  the  fauces. 

The  lingual  lymphatics  (Fig.  34)  are  large  and 
numerous,  and  offer  a  free  channel  for  the  dissem- 
ination of  cancerous  emboli.  They  are  arranged 
in  two  systems  :  (1)  Superficial,  forming  an  ex- 
tremely rich  plexus  in  the  submucous  tissue  on 
the  dorsum  and  sides  of  the  tongue;  (2)  deep, 
arranged  as  a  network  in  the  musculature  of 
the  tongue.  These  two  systems  are  in  free  com- 
munication; Cheatle  found  that  the  genio-glossus 
muscle  was  a  common  site  of  secondary  deposit  in 
cases  of  cancer  of  the  tongue.  The  lymph  from 
these  two  systems  is  carried  off  by  the  following 
sets  of  efferent  vessels:  (1)  the  marginal  or  lateral 


158  THE    HEAD    AND    NECK  [CHAP. 

vessels,  which  leave  the  submucous  plexus  on  the 
side  of  the  tongue  and  pass  partly  to  the  sub- 
mandibular  group  of  glands  and  partly  to  the 
upper  deep  cervical  group ;  (2)  the  central  vessels, 
which  form  between  the  two  genio-glossus  muscles 
and  end  in  the  upper  deep  cervical  glands;  (3)  the 
apical  vessels,  which  end  in  the  submental  gland 
and  in  the  upper  deep  cervical ;  (4)  the  basal 
vessels  frona  the  posterior  third  of  the  tongue 
which  terminate  in  the  upper  deep  cervical 
group.*  The  main  vessels  become  blocked  by  the 
invasion  of  cancer  cells,  so  that  the  lymph  has 
to  seek  by-paths  and  circuitous  routes,  which  also 
in  time  become  occluded.  Thus  the  cancerous 
invasion  may  become  widely  spread  and  in  many 
directions.  The  lymphatic  glands  over  the  sub- 
mandibular  gland,  the  lymphoid  tissue  in  that 
gland  and  in  the  sublingual,  become  the  seats 
of  secondary  deposit.  The  submental  gland  may 
also  be  affected. 

In  the  strange  congenital  affection  known  as 
macroglossia  the  tongue  becomes  much  enlarged, 
and  in  some  cases  may  attain  ^prodigious  dimen- 
sions. The  enlargement  is  primarily  due  to  the 
greatly  dilated  condition  of  the  lymphatic  chan- 
nels of  the  organ  (hence  the  name,  lymphangioma 
cavernosum,  proposed  by  Virchow),  and  to  an  in- 
creased development  of  lymph  tissue  throughout 
the  part.  The  portion  most  conspicuously  affected 
is  the  base  of  the  tongue,  where  the  lymphatics 
are  usually  the  most  numerous. 

Accessory  glands  about  the  tongue.— 
Accessory  glands,  belonging  to  the  thyroid  body, 
are  frequently  found  in  the  vicinity  of  the 
hyoid  bone.  They  are  also  found  in  the  basal 
part  of  the  tongue,  near  the  foramen  caecum 
(Makins).  Some  may  be  superficial  to  the  mylo- 
hyoid  muscle,  others  may  be  just  above  the 
hyoid  bone,  and  others  in  the  hollow  of  that 
bone.  Cysts  lined  with  ciliated  epithelium  may 

'     *  For  a  full  account  of  the  lymphatics  see  Poirier's  "Lymphatics, 
translated  by  Cecil  Leaf,  1903. 


vni]  EXCISION   OF  THE   TONGUE  159 

sometimes  be  found  in  the  same  situations. 
All  these  structures  are  the  remains  of  the 
neck  of  the  central  diverticulum  which  is  pro- 
truded from  the  ventral  wall  of  the  pharynx  in 
the  embryo,  and  from  which  the  isthmus  and 
adjoining  part  of  the  thyroid  gland  are  formed. 
The  foramen  ccecum  on  the  tongue  indicates 
the  spot  where  this  diverticulum  arises  from 
the  pharynx.  Ducts  lined  with  epithelium  have 
been  found  leading  from  the  foramen  caecum  to 
accessory  glands  about  the  hyoid  bone.  From 
these  glandular  and  epithelial  collections  about 
the  hyoid  bone  certain  deep-seated  forms  of  cancer 
of  the  neck  may  be  developed.  Some  of  these 
take  the  form  of  malignant  cysts  described  by 
the  author  (Path.  Soc.  Trans.,  1886). 

Excision.— Many  different  methods  have  been 
adopted  for  the  removal  of  the  entire  tongue.  It 
has  been  removed  through  the  mouth  by  the  ecra- 
seur  or  the  scissors,  the  latter  operation  being  per- 
formed with  or  without  previous  ligature  of  the 
lingual  arteries  in  the  neck.  It  is  difficult,  however, 
fully  to  expose  the  deeper  attachments  of  the  organ 
through  the  comparatively  small  orifice  of  the 
mouth.  To  obtain  more  room  the  cheek  has  been 
slit  up  in  one  procedure,  while  the  lower  lip  and 
symphysis  of  the  lower  jaw  have  been  divided  in 
another. 

In  another  series  of  operations  the  tongue  has 
been  reached,  or  the  organ  has  been  fully  exposed, 
by  an  incision  made  between  the  hyoid  bone  and 
the  mandible.  Kocher  introduced  the  method  of 
exposing  the  tongue  from  the  neck,  reaching  it 
by  an  incision  commencing  near  the  ear  and  fol- 
lowing the  anterior  border  of  the  sterno-mastoid 
muscle  as  far  as  the  hyoid  bone,  whence  it  turns 
upwards  along  the  anterior  belly  of  the  digastric 
muscle.  This  method,  besides  giving  an  'oppor- 
tunity of  completely  controlling  haemorrhage  by  a 
preliminary  ligature  of  the  lingual  artery,  allows 
free  removal  of  the  upper  deep  cervical  glands,  the 
lymphatic  glands,  and  the  tissue  over  and  in  the 


100  THE   HEAD   AND  NECK  [CHAP. 

submandibular  and  sublingual  glands  which  form 
the  seats  of  secondary  cancerous  deposits. 

In  the  removal  of  the  entire  organ,  the 
following  parts  are  of  necessity  divided :  The 
frenum,  the  mucous  membrane  along  the  sides  of 
the  tongue,  the  glosso-epiglottic  folds,  the  genio- 
glossus,  hyo-glossus,  stylo-glossus.  palato-glossus 
muscles,  the  few  fibres  of  the  superior  and  inferior 
lingual  muscles  which  are  attached  to  the  hyoid 
bone,  the  terminal  branches  of  the  lingual,  glosso- 
pharyngeal,  and  hypoglossal  nerves,  the  lingual 
vessels,  and,  at  the  side  of  the  tongue  near  its 
base,  some  branches  of  the  ascending  pharyngeal 
artery  and  of  the  tonsillar  branch  of  the  facial 
artery. 

THE  PALATE 

The  arch  of  the  hard  palate  varies  in  height 
and  shape  in  different  individuals;  it  is  particu- 
larly narrow  and  high  in  those  who  have  suffered 
in  youth  from  adenoids.  The  outline  of  this 
arch  is  of  some  moment  in  operations  upon  the 
palate. 

Cleft  palate. — In  order  to  understand  the 
various  forms  of  cleft  which  occur  in  the  palate 
and  upper  lip,  it  is  necessary  to  review  briefly 
the  development  of  these  parts;  for  all  forms 
of  cleft  palate  and  "hare-lip"  are  due  to  an 
incomplete  fusion  of  parts.  In  Fig.  39,  A,  the 
bony  palate  at  birth  is  shown  to  be  made  up 
of  three  elements :  (1)  the  premaxillary  (os 
incisivum),  carrying  the  four  incisor  teeth ;  (2) 
the  right  maxillary;  (3)  the  left  maxillary,  bear- 
ing the  right  and  left  canines  and^milk  molars. 
These  three  parts  are  different  in  origin  :  the  pre- 
maxillary part  is  developed  in  the  mesial  nasal 
process  (Fig.  29,  p.  124) ;  the  maxillary  parts  from 
the  right  and  left  maxillary  processes.  Fusion 
of  the  various  elements  to  form  the  palate  com- 
mences anteriorly  and  proceeds  backwards.  In 
the  posterior  two-thirds  of  the  palate  the  maxillary 
processes  fuse  with  each  other  in  the  median  line, 


viii]       DEVELOPMENT   OF   BONY   PALATE       161 

but  in  the  anterior  third  they  unite  with  the 
premaxillary  part.  Thus  the  line  of  fusion  is 
Y-shaped,  the  premaxillary  part  occupying  the 
fork.  In  the  majority  of  cases  the  cleft  occurs  in 
the  position  of  the  main  stem  of  the  Y,  or  it  may 
.affect  only  the  soft  palate;  or  it  may  extend 
forwards  to  the  alveolus  on  one  side  or  on  both,  as 
is  shown  in  Fig.  39,  B,  c.  The  lateral  incisor  is 
developed  in  the  groove  between  the  premaxillary 
and  maxillary  elements;  if  the  condition  of  cleft 


Fig.  39. — Illustrating  the  relationship  of  the  lateral  incisor 
tooth  to  the  palatal  cleft. 

A,  Normal  hard  palate.    The  premaxilla  is  stippled  ;  the  lateral 

incisor  occurs  in  the  suture  between  it  and  the  maxilla. 

B,  Double  cleft  palate,  the  lateral  incisor  being  situated  on  the 

premaxilla  to  the  inner  side  of  the  cleft.  The  septum  of  the  nose 
is  exposed  in  the  cleft  between  the  maxillary  bones. 
c,  Double  cleft  palate,  the  lateral  incisor  being  situated  on  the 
maxilla  to  the  outer  side  of  the  cleft. 

palate  occurs,  the  developmental  elements  separate 
as  growth  proceeds;  the  bud  of  the  lateral  incisor 
may  adhere  to  either  side  of  the  cleft  thus  formed ; 
hence  in  some  cases  this  incisor  is  found  on  the 
premaxillary  process ;  In  others,  in  the  maxillary 
(Fig.  39,  B,  c).  Each  premaxilla  may  show  two 
centres  of  ossification,  but  the  cleft  is  not,  as 
is  so  often  said,  the  result  of  the  failure  of 
union  of  two  centres  of  ossification,  but  is  due 
to  the  separation  of  the  developmental  parts  of 
the  palate. '  As  growth  goes  on  during  childhood 
the  cleft  becomes  wider. 

The  upper  lip  is  developed  from  the  same  three 


162  THE  HEAD   AND  NEGK  [CHAP. 

elements  as  the  palate  (Fig.  29,  p.  124) ;  if  the 
palatal  cleft  extends  to  the  alveolus  the  lip  is  also 
affected,  but  a  cleft  on  one  or  both  sides  of  the 
lip  may  occur  without  a  cleft  of  the  palate.  The 
premaxillary  or  median  element  of  the  lip  is  also 
bilateral  in  origin,  but  it  is  extremely  rare  to 
find  a  persistent  separation  of  its  two  parts.  In 
cases  of  double  hare-lip  one  sees  occasionally  two 
papillae  on  the  lower  lip,  fitting  into  the  clefts  in 
the  upper  when  the  lips  are  in  apposition. 

The  mucous  membrane  covering  the  hard 
palate  is  peculiar  in  that  it  is  practically  one 
with  the  periosteum  covering  the  bones;  and, 
therefore,  in  dissecting  up  this  membrane  the  bone 
is  bared,  as  the  mucous  membrane  and  the  perios- 
teum cannot  be  separated.  The  membrane  is  thin 
in  the  middle  line,  but  is  much  thicker  at  the  sides 
near  the  alveoli,  the  increased  thickness  depend- 
ing mainly  upon  the  introduction  of  a  number 
of  mucous  glands  beneath  the  surface  layers,  such 
glands  being  absent  in  the  middle  line.  The 
density  and  toughness  of  the  soft  covering  of  the 
hard  palate  render  it  very  easy  to  manipulate 
when  dissected  up  in  the  form  of  flaps,  as  in  the 
operation  for  cleft  palate. 

Sir  Rickman  Godlee  has  described  a  number 
of  cases  in  which  a  bony  elevation — the  torus 
palatinus — is  found  on  the  posterior  part  of  the 
under  surface  of  the  hard  palate.  The  elevation 
or  exostosis  is  commoner  in  lower  races  than  in 
Europeans,  and  begins  to  form  as  adult  life  is 
reached.  It  is  due  to  a  heaping-up  of  bone  on 
each  side  of  the  median  suture  of  the  palate, 
and  in  exceptional  cases  attains  noticeable 
dimensions. 

The  main  blood  supply  of  the  bones  of  the 
hard  palate  and  of  its  mucous  covering  is  derived 
from  the  descending  palatine  branch  of  the  in- 
ternal maxillary  artery.  This  vessel,  which  is 
practically  the  only  vessel  of  the  hard  palate, 
emerges  from  the  posterior  palatine  canal  near 
the  junction  of  the  hard  palate  with  the  soft,  and 


vni J  THE  SOFT   PALATE  163 

close  to  the  inner  side  of  the  last  molar  tooth. 
The  vessel  runs  forwards  and  inwards  to  end 
at  the  anterior  palatine  canal.  Its  pulsations  on 
the  palate  can  often  be  distinctly  felt.  In  dis- 
secting up  muco-periosteal  flaps  from  the  hard 
palate  by  means  of  a  raspatory,  it  is  most 
important  to  make  the  initial  incision  in  the 
mucous  membrane  close  to  the  alveolus,  so  that 
the  flap  may  include  this  artery,  and  its  vitality 
thereby  be  secured.  In  dissecting  up  the  flap  it 
should  be  remembered  that  the  artery  runs  much 
nearer  to  the  bone  than  to  the  mucous  surface. 

The  soft  palate  is  of  uniform  thickness,  its 
average  measurement  being  estimated  at  about 
5  of  an  inch.  Its  thickness  is  largely  due  to 
a  stratum  of  mucous  glands  on  its  upper  sur- 
face. Its  central  basis  is  a  tendinous  expansion, 
the  palatal  aponeurosis,  in  which  the  tensors 
of  the  palate  end  and  by  which  they  are  at- 
tached to  the  posterior  border  of  the  hard 
palate.  When  the  soft  palate  is  congenitally  cleft, 
the  edges  of  the  fissure  are  approximated  dur- 
ing swallowing  by  the  uppermost  fibres  of  the 
superior  constrictor.  This  approximation  may 
narrow  the  cleft  by  one-half  or  two-thirds.  The 
muscles  that  tend  to  widen  the  cleft  are,  in 
the  main,  the  levator  palati  and  tensor  palati. 
It  is  necessary  that  these  muscles  should  be 
divided  in  attempting  to  close  the  cleft  by 
operation.  The  levator  palati  crosses ^ the  palate 
obliquely  from  above  downwards  and  inwards  on 
its  way  to  the  middle  line,  lying  nearer  to  the 
upper  than  the  lower  surface  of  the  velum.  The 
tensor  palati  turns  round  the  hamular  process, 
and  passes  to  the  middle  line  in  a  nearly  hori- 
zontal direction  (Fig.  40).  The  hamular  process 
can  be  felt  through  the  soft  palate  just  behind 
and  to  the  inner  side  of  the  last  upper  molar 
tooth.  When  the  muco-pcriosteum,  containing  the 
posterior  palatine  vessels,  has  been  raised  from 
the  hard  palate  on  each  side  of  the  cleft,  so  that 
the  hinder  border  of  the  horizontal  plate  of  the 


164 


THE  HEAD   AND   NEGK 


[CHAP. 


palate  bone  is  exposed,  the  operator  separates 
the  palatal  aponeurosis  and  the  overlying  mucous 
membrane  on  the  nasal  aspect  from  the  palate 
bone,  taking  care  to  stop  short  of  the  posterior 
palatine  canal  and  palatine  vessels.  When  the 
aponeurosis  is  cut  through  the  tensor  palati  is 
partly  thrown  out  of  action.  The  levator  palati 


EUSTACH.TUBl. 
LEV.  PALATI 


Fig.  40.— Muscles  of  the  soft  palate,  from  behind. 

(Blake  w  ay .} 

is  best  cut  as  it  enters  the  upper  surface  of 
the  soft  palate  within  a  raised  fold  of  mucous 
membrane.  Its  nerve  enters  the  upper  end  of 
the  muscle,  and  is  thus  left  undamaged  (Berry 
and  Legg). 

The  blood  supply  of  the  soft  palate  is  derived 
from  the  descending  palatine  branch  of  the  in- 
ternal maxillary  artery,  the  ascending  pharyn- 


vm]  THE   PHARYNX  165 

geal  artery,  and  the  ascending  palatine  branch 
of  the  facial  artery.  The  latter  vessel  reaches  the 
velum  by  following  the  levator  palati  muscle,  and 
must  be  divided  in  the  section  made  of  this  muscle 
in  the  procedure  just  described. 

The  muscles  of  the  soft  palate  are  supplied  by 
several  nerves.  The  levator  palati,  azygos  uvulae, 
and  palato-pharyngeus  are  innervated  with  the 
muscles  of  the  pharynx  by  the  spinal  accessory; 
the  palato-glossus  with  the  muscles  of  the  tongue 
from  the  hypoglossal,  and  the  tensor  palati  with 
the  tensor  tympani  from  the  third  division  of  the 
fifth  nerve  through  the  otic  ganglion. 

THE  PHARYNX 

The  pharynx  is  about  5  inches  in  length. 
It  is  much  wider  from  side  to  side  than  from 
before  backwards.  It  is  widest  at  the  level  of  the 
tip  of  the  greater  cornua  of  the  hyoid  bone,  where 
it  measures  about  2  inches.  It  is  narrowest  where 
it  joins  the  gullet  opposite  the  cricoid  cartilage, 
its  diameter  here  being  less  than  f  of  an  inch. 
The  pharynx  is  not  so  Targe  a  space  as  supposed, 
for  it  must  be  remembered  that  during  life  it  is 
viewed  very  obliquely,  and  erroneous  notions  are 
thus  formed  of  its  antero- posterior,  dimensions. 
The  distance  from  the  arch  of  the  teeth  to  tho 
commencement  of  the  gullet  is  about  6  to  7  inches, 
a  measurement  that  should  be  borne  in  mind 
in  extracting  foreign  bodies.  Foreign  bodies 
passed  into  the  pharynx  are  most  apt  to  lodge 
at  the  level  of  the  cricoid  cartilage,  a  point  that, 
in  the  adult,  is  a  little  beyond  the  reach  of 
the  finger.  The  history  of  foreign  bodies  in  the 
pharynx  shows  that  that  cavity  is  very  dilatable, 
and  can  accommodate  for  some  time  large  sub- 
stances. Thus,  in  a  case  reported  by  Dr.  Geoghe- 
gan,  a  man  of  60,  who  for  months  had  had  some 
trouble  in  his  throat  for  which  he  could  not 
account,  was  supposed  to  have  cancer.  On  ex- 
amination, however,  a  plate  carrying  five  false 
teeth,  and  presenting  niches  for  five  natural  ones, 


J66  THE  HEAD   AND   NECK  [CHAP. 

was  found  embedded  in  the  pharynx,  where  it 
had  been  lodged  for  five  months.  The  plate  had 
been  swallowed  during  sleep  (Med.  ljrtss,  1866). 
In  the  Lancet  for  1868  is  an  account  of  a  mutton 
chop  that  became  lodged  in  the  pharynx  of  a 
gluttonous  individual.  The  chop  presented  the 
ordinary  vertebral  segment  of  bone,  together  with 
l\  inches  of  rib,  and  was  "  pretty  well  covered 
with  meat."  Attempts  to  remove  it  failed,  and 
it  was  finally  vomited  up.  Dr.  Hicks  (Lancet, 
1884)  reports  the  case  of  a  woman  who  committed 
suicide  by  cramming  half  a  square  yard  of  coarse 
calico  (belonging  to  her  nightdress)  into  her 
mouth  and  throat. 

The  walls  of  the  pharynx  are  in  relation  with 
the  base  of  the  skull,  and  with  the  upper  six  cer- 
vical vertebrae.  The  arch  of  the  atlas  is  almost 
exactly  on  a  line  with  the  hard  palate.  The  axis 
is  on  a  line  with  the  free  edge  of  the  upper  teeth. 
The  termination  of  the  pharynx  corresponds  to 
the  sixth  cervical  vertebra.  The  upper  vertebrae 
can  be  examined,  as  regards  their  anterior  sur- 
face, from  the  mouth.  When  the  bones  about  the 
pharynx  are  diseased,  the  necrosed  parts  may  be 
discharged  by  that  cavity.  Thus  portions  of  the 
atlas  and  axis  have  been  expelled  by  the  mouth, 
as  also  have  been  some  fragments  of  comparatively 
large  size  thrown  off  by  the  occipital  and  sphenoid 
bones. 

The  mucous  membrane  of  the  pharynx  is  vas- 
cular, and  readily  inflamed;  and  such  inflamma- 
tions are  peculiarly  dangerous,  in  that  they  may 
spread  to  the  lining  membrane  of  the  larynx. 
The  submucous  tissue  of  the  aryteno-epiglottic 
folds  and  of  the  neighbouring  part  of  the  pharynx 
is  peculiarly  loose,  and  in  oBdematous  conditions 
the  upper  aperture  of  the  larynx  may  be  almost 
closed. 

Much  adenoid  tissue  is  distributed  in  the 
mucous  membrane  of  the  pharynx,  and  it  is  this 
tissue  that  is  the  primary  seat  of  inflammation 
in  various  forms  of  pharyngitis.  A  distinct  col- 


mi]  POSTNASAL   GROWTHS  167 

lection  of  adenoid  tissue — the  pharyngeal  tonsil 
— is  found  in  the  roof  of  the  naso-pharynx 
(see  Figs.  41  and  27).  It  is  embedded  in  thick 
mucous  membrane,  and  extends  from  the  base  of 
the  septum  of  the  nose  to  the  mid-point  of  the 
basilar  process  of  the  skull.  The  centre  of  the  ton- 
sil is  marked  by  a  fissure  or  depression  bounded 
on  each  side  by  two  or  three  folds  of  mucous 
membrane  laden  with  adenoid  tissue.  It  reaches 
its  maximum  size  about  the  tenth  year.  ^  It  ex- 
tends laterally  towards  the  recesses  behind  the 
Eustachian  tubes, 
and  may  invade 
these  recesses  and  -/mmf&i  %£^™ar  ROOF  OF 

thus       prevent       the       ^^^^^^^^      NASO-PHARYNX 

free  opening  of  the 

tubes     This  deposit     mm^^mm 

of    adenoid     tissue     Wem£&&iiL  ^m—  EUSTACH.  TL 


the  condition  known 

as      "  adenoid      Vege-  POST.  BORDER  OF 

tations  "   or   "  post-  SEPTUM  NAS1 

nasal  growths"  be  Fig.  41.— Tonsil  of  the  naso-pharynx 
produced.  These  of  a  boy  aged  2  years, 

growths  may  cause    (From  a  preparation  made  by  Prof . 
deafness    and    may  Symington.) 

block  the  posterior 

nares.  They  need  to  be  removed  by  operation. 
They  are  supplied  by  minute  arteries  derived 
from  the  internal  maxillary  (Vidian  and  pterygo- 
palatine)  and  from  the  ascending  pharyngeal. 
The  veins  join  the  pharyngeal  plexus,  and  the 
lymphatics  drain  to  the  retropharyngeal  gland, 
thence  to  the  deep  cervical  glands. 

The  tissue  immediately  outside  the  pharyngeal 
walls  is  lax,  and  favours  the  spread  of  effusion. 
Thus,  in  acute  inflammation  of  the  pharynx  the 
effusion  has  been  found  to  extend  along  the 
esophagus,  reaching  the  posterior  mediastinum, 
and  advancing  even  to  the  diaphragm.  In  the  lax 
connective  tissue  between  the  pharynx  and  the 


168  THE   HEAD  AND  NECK  [CHAP. 

spine  abscess  is  not  infrequent,  due,  as  a  rule,  to 
caries  of  the  vertebrae  (postpharyngeal  abscess). 
In  this  connective  tissue,  and  opposite  the  axis, 
is  also  found  a  lymphatic  gland  that  receives 
lymphatics  from  the  nasal  cavity  and  naso- 
pharynx. This  gland  may  prove  the  seat  of  a 
suppuration.  Such  collections  may  so  push  for- 
ward the  posterior  pharyngeal  wall  as  to  depress 
the  soft  palate,  or  may  cause  severe  dyspnoea 
by  interference  with  the  larynx.  The  matter  may 
discharge  itself  through  the  mouth,  or  may  reach 
the  neck  by  passing  behind  the  great  vessels  and 
the  parotid  gland,  presenting  ultimately  beneath 
or  at  one  border  of  the  sterno-mastoid  muscle. 

Many  structures  of  importance  are  in  relation 
with  the  lateral,  walls  of  the  pharynx,  the  prin- 
cipal being  the  internal  carotid  artery,  the  vagus, 
glosso-pharyngeal,  and  hypoglossal  nerves  (Fig. 
34,  p.  134).  The  internal  carotid  is  so  close  to 
the  pharynx  that  its  pulsations  may  be  felt  by 
the  finger  introduced  through  the  mouth.  These 
and  other  deep  structures  in  the  neck  may  be 
wounded  by  foreign  bodies  that,  passing  in  at 
the  mouth,  have  been  thrust  through  the  pharynx 
into  the  cervical  tissues.  The  internal  jugular 
vein  is  at  some  distance  from  the  pharynx,  espe- 
cially at  its  upper  part  (Fig.  34,  p.  134).  The 
styloid  process,  when  prominent,  and  an  ossified 
stylo-hyoid  ligament,  can  also  be  felt  at  the  side 
of  the  pharynx  immediately  behind  the  tonsil. 
In  more  than  one  case  an  ossified  stylo-hyoid 
ligament  has  been  mistaken  for  a  foreign  body, 
and  an  attempt  made  to  excise  it. 

The  tonsil  (Figs.  42,  43)  is  lodged  between  the 
anterior  and  posterior  palatine  arches.  It  is  in 
relation  externally  with  the  superior  constrictor 
muscle  (Fig.  34,  p.  134),  and  it  corresponds,  as 
regards  the  surface,  to  the  angle  of  the  lower  jaw. 
When  hyper  trophied,  the  mass  tends  to  develop 
towards  the  middle  line,  where  no  resistance  is 
encountered,  and  to  effect  but  little  change  in 
its  external  relations.  The  mass,  often  mistaken 


vin]  THE   TONSIL  169 

for  the  enlarged  tonsil  in  the  neck,  is  formed 
of  enlarged  glands,  situate  near  the  tip  of  the 
great  cornu  of  the  hj^id  bone,  and  overlying 
the  internal  jugular  vein.  These  glands  receive 
the  tonsillar  lymphatics,  and  are  almost  invari- 
ably enlarged  in  all  tonsil  affections.  The  fact 
that  these  glands  are  so  frequently  the  first  to  en- 
large when  the  cervical  glands  become  tuberculous 
points  to  the  tonsil  as  a  common  site  of  primary 
infection.  The  tonsil  is  closely  enough  attached  to 


SOFT  PALATE 
PLICA  SEMILUNARI 


TONGUE 


EPIGLOTTIS 


Fig.  42.— Diagram  of  the  pillars  of  the  fauces  and  of  the 
tonsil. 

the  pharyngeal  wall  to  be  affected  by  the  movements 
of  the  pharyngeal  muscles  (Fig.  43).  Thus  it  is 
moved  inwards  by  the  superior  constrictor  muscle 
during  the  act  of  swallowing,  and  may  be  drawn 
outwards,  on  the  other  hand,  by  the  stylo-pharyn- 
geus  muscle.  The  ease  with  which  a  tonsil  can  be 
reached  depends,  other  things  being  equal,  upon 
the  extent  to  which  it  can  be  withdrawn  by  the 
stylo-pharyngeus,  and  upon  the  development  of 
the  anterior  palatine  arch,  which,  to  some  extent, 
hides  the  tonsil.  A  child  with  a  prominent  an- 
terior palatine  arch,  containing  a  well-developed 


170 


THE   HEAD   AND  NECK 


[CHAP. 


palato-glossus  muscle,  and  with  a  vigorous  stylo- 
pharyngeus,  can  for  a  long  time  elude  the  tonsil 
guillotine.  Nevertheless  the  tonsil  can  be  re- 
moved intact  and  with  its  capsule  still  adherent 
to  it.  The  extent  to  which  a  tonsil  projects 
beyond  the  level  of  the  pillars  is  no  index  to  its 
real  size  (Pybus). 

The  tonsil  is  variable  in  shape ;  it  is  frequently 
divided  into  three  masses,  and,  besides  numerous 


SUP.  CONSTRICTOR 


STYLO~PHARYNQE:US 
STYLO-GLOSSUS 


TONSIL 

ANTER.  PILLAR 

PAL ATO -GLOSS 


MANOIB. 
NERVE. 


CONSTRIC'TOA 

Sr* MOLAR 
BUCCINATOR 

Fig.  43. — Horizontal  section  across   the  tonsil  and  its 
capsule,  and  the  pillars  of  the  fauces. 

crypts,  shows  towards  its  upper  part,  where  the 
anterior  and  posterior  pillars  meet  with  the  soft 
palate,  a  deep  recess  or  pocket — the  tonsillar 
recess.  This  recess  is  the  remnant  of  the  first 
visceral  cleft  in  which  the  tonsil  was  developed 
(Seccombe  Hett).  From  the  anterior  pillar  a 
sharp  fold  of  mucous  membrane  passes  back- 
wards, to  end  on  the  tonsil — the  plica  triangularis 
(Fig.  42)— while  another  fold  may  join  the  pil- 
lars over  the  tonsillar  racess  (plica  semilunaris}. 


vin]  HYPERTROPHIED   TONSIL  171 

The  tonsil  is  separated  from  the  superior  con- 
strictor by  a  fine  fibrous  capsule  (Fig.  43) ;  its 
lymphatics  perforate  the  constrictor.  Two  chief 
forms  of  tonsil  may  be  recognized :  the  embedded, 
where  the  adenoid  tissue  increases  beneath  the 
level  of  the  pillars ;  and  the  projecting^  where 
the  increase  affects  chiefly  the  exposed  part  of  the 
tonsil  (S.  Hett). 

Deafness  is  often  complained  of  when  the  tonsil 
is  hypertrophied.  This  is  not  due  to  closure  of 
the  Eustachian  tube  by  the  direct  pressure  of  the 
enlarged  mass;  such  pressure  is  anatomically 
impossible.  The  large  tonsil  may,  however,  affect 
the  patency  of  the  tube,  by  disturbing  the  soft 
palate,  and  through  it  the  tensor  palati  muscle, 
which  is  much  concerned  in  keeping  open  the 
Eustachian  tube.  The  deafness  in  these  cases  is 
probably  due  rather  to  an  extension  of  the  hyper- 
trophic  process  to  the  lining  membrane  of  the 
tube  than  to  any  pressure  effects,  since  it  is 
usually  not  improved  until  some  time  after  the 
tonsil  has  been  removed.  The  tonsillar  tissue  is 
for  the  most  part  collected  around  a  number  of 
crypts  (Fig.  43).  The  decomposition  of  retained 
epithelial  structures  within  these  recesses  pro- 
duces the  fetid  breath  often  noticed  in  cases  of 
enlarged  tonsil,  and  probably  incites  the  attacks 
of  inflammation  to  which  such  tonsils  are  liable. 
Calculi  may  form  in  these  crypts  and  give  rise 
to  a  spasmodic  cough.  In  this  case  the  glosso- 
pharyngeal  nerve  conveys  the  afferent  impulse  to 
the  respiratory  centre. 

The  tonsil  is  very  vascular,  receiving  blood 
from  the  tonsillar  and  palatine  branches  of  the 
facial  artery,  from  the  descending  palatine  branch 
of  the  internal  maxillary,  from  the  dorsalis  lin- 
guae of  the  lingual,  and  from  the  ascending 
pharyngeal.  Hence  the  operation  of  removing 
the  tonsil  is  often  associated  with  free  bleeding. 
The  internal  carotid  artery  is  close  to  the 
pharynx,  but  some  way  behind  the  gland  (Fig.  34, 
p.  134).  The  vessel  is,  indeed,  about  \  of  an  inch 


172  THE  HEAD   AND   NECK 

posterior  to  that  body,  and  is  in  comparatively 
little  danger  of  being  wounded  when  the  tonsil 
is  excised.  The  internal  jugular  vein  is  a  con- 
siderable distance  from  the  tonsil.  The  facial 
artery,  in  its  cervical  stage,  is  close  to  the  tonsil. 
Of  important  cervical  structures,  the  nearest  to 
the  tonsil  is  the  glosso-pharyngeal  nerve.  The 
ascending  pharyngeal  artery  is  also  in  close  re- 
lation with  it.  Although  this  vessel  is  of  small 
size,  bleeding  from  it  has  proved  fatal,  as  the 
following  interesting  case,  reported  by  Mr.  Mor- 
rant  Baker,  will  show  : 

A  man  aged  23  fell  when  drunk,  and  grazed  his  throat 
with  the  end  of  a  tobacco-pipe  he  was  smoking1  at  the  time. 
He  thought  nothing-  of  the  accident.  In  two  days  he  came 
to  the  hospital  with  what  appeared  to  be  an  acutely  inflamed 
tonsil.  The  tonsil  was  punctured,  but  nothing  escaped  save 
a  little  blood.  Several  haemorrhages  occurred  from  the  tonsil 
wound,  and  on  the  fourth  day  after  the  accident  1  inch  of 
the  stem  of  a  clay  pipe  was  discovered  deeply  embedded  in 
the  glandular  substance.  It  was  removed,  and  the  common 
carotid  tied.  The  patient,  however,  never  rallied  from  the 
previous  severe  haemorrhages,  and  soon  died.  The  autopsy 
showed  that  the  stem  of  the  pipe,  which  had  not  been  missed 
by  the  patient,  had  divided  the  ascending  pharyngeal  artery. 
(SH,  Hart:*  Hosp.  Report*,  1870.) 

The  tonsil  is  often  the  seat  of  malignant 
growths.  Such  tumours  have  been  removed 
through  the  mouth,  but  are  more  conveniently 
dealt  with  through  an  incision  in  the  neck  along 
the  anterior  edge  of  the  sterno-mastoid  (Cheevers' 
operation). 


CHAPTER    IX 
THE   NECK 

Surface    anatomy;    bony    points. — The   by  old 

bone  is  on  a  level  with  the  fourth  cervical  vertebra, 
while  the  cricoid  cartilage  is  opposite  the  sixth. 
The  upper  margin  of  the  sternum  is  on  a  level 
with  the  disc  between  the  second  and  third 
dorsal  vertebrae.  (See  p.  187.)  At  the  back  of  the 
neck  there  is  a  slight  depression  in  the  middle 
line  which  descends  from  the  occipital  protuber- 
ance, and  lies  between  the  prominences  formed  by 
the  trapezius  and  complexus  muscles  of  the  two 
sides.  At  the  upper  part  of  this  depression  the 
spine  of  the  axis  can  be  made  out  on  deep  pres- 
sure. Below  this,  the  bony  ridge  formed  by  the 
spines  of  the  third,  fourth,  fifth,  and  sixth  cervi- 
cal vertebrae  can  be  felt,  but  the  individual  spines 
cannot  usually  be  distinguished.  At  the  root  of 
the  neck  the  spinous  process  of  the  vertebra 
prominens  is  generally  very  obvious.  The  trans- 
verse process  of  the  atlas  may  be  felt  just  below 
and  in  front  of  the  tip  of  the  mastoid  process. 
By  deep  pressure  in  the  upper  part  of  the  supra- 
clavicular  fossa,  the  transverse  process  of  the 
seventh  cervical  vertebra  can  be  distinguished. 
If  pressure  be  made  over  the  line  of  the  carotid 
vessels  at  the  level  of  the  cricoid  cartilage, 
the  prominent  anterior  tubercle  of  the  trans- 
verse process  of  the  sixth  cervical  vertebra 
can  be  felt.  This  is  known  as  the  "carotid  tuber- 
cle." The  carotid  artery  lies  directly  over  it, 
and  in  ligaturing  that  vessel  some  surgeons  make 
important  use  of  this  tubercle  as  a  landmark.  If 
a  horizontal  section  of  the  neck,  in  a  muscular 
v  173 


174  THE    HEAD    AND    NECK  [CHAP. 

subject,  taken  about  the  level  of  the  sixth  cervical 
vertebra,  be  viewed,  the  whole  of  the  body  of  the 
vertebra  divided  will  be  seen  to  lie  within  the 
anterior  half  of  the  section. 

Middle  Iiiie.—-In  the  receding  angle  below 
the  chin  the  hyoid  bone  can  be  felt  and  its 
body  and  greater  cornua  well  made  put.  About 
a  finger's-breadth  below  it  is  the  thyroid  cartilage. 
The  details  of  this  latter  are  readily  distin- 
guished, and  below  it  the  cricoid  cartilage,  crico- 
thyroid  space,  and  trachea  can  be  easily  recog- 
nized. The  separate  rings  of  the  trachea  cannot 
be  felt.  The  trachea  is  less  easily  made  out  as  it 
passes  down  the  neck  As  it  descends  it  takes  a 
deeper  position,  and  at  the  upper  border  of  the 
sternum  lies  nearly  1^  inches  from  the  surface. 

The  rima  glottidis  corresponds  to  the  middle 
of  the  anterior  margin  of  the  thyroid  cartilage. 

Unless  enlarged,  the  thyroid  gland  cannot 
be  made  out  with  certainty.  According  to  Holden, 
the  pulse  of  the  superior  thyroid  artery  can  be 
felt  at  its  upper  and  anterior  part. 

The  anterior  jugular  veins  descend  on  either 
side  of  the  middle  line  upon  the  sterno-hyoid  mus- 
cles. They  commence  in  the  submandibular  region, 
pierce  the  fascia  just  above  the  inner  end  of  the 
clavicle,  and,  passing  beneath  the  origin  of  the 
sterno-mastoid  muscle,  end  in  the  external  jugu- 
lar. The  inferior  thyroid  veins  lie  in  front  of 
the  trachea,  below  the  isthmus. 

Side  of  the  neck.  Muscles.— The  sterno- 
mastoid  muscle,  especially  in  thin  subjects  and 
when  thrown  into  action,  is  a  prominent  feature 
in  the  neck.  The  anterior  border  of  the  muscle  is 
very  distinct.  The  posterior  border  is  less  promi- 
nent, especially  at  its  upper  part.  A  communi- 
cating branch  from  the  facial  vein  generally  runs 
along  the  anterior  border  of  the  muscle  to  meet 
the  anterior  jugular  vein  at  the  lower  part,  of 
the  neck.  The  interval  between  the  sternal  and 
clavicular  parts  of  the  muscle  is  generally  well 
marked.  If  a  needle  be  thrust  through  this  in- 


ix]  VESSELS   OF  THE  NEGK  175 

terval,  quite  close  to  the  clavicle,  it  would  just 
touch  the  bifurcation  of  the  innominate  artery 
on  the  right  side  and  would  pierce  the  carotid 
vessel  on  the  left.  The  posterior  belly  of  the 
digastric  muscle  corresponds  to  a  line  drawn  from 
the  mastoid  process  to  the  anterior  part  of  the 
hyoid  bone.  The  anterior  belly  of  the  omo-hyoid 
follows  an  oblique  line  drawn  downwards  from  the 
fore  part  of  the  hyoid  bone,  so  as  to  cross  the 
line  of  the  carotid  artery  opposite  the  cricoid 
cartilage.  The  posterior  belly  can  be  made  out  in 
thin  necks,  especially  when  in  action,  running 
nearly  parallel  with  and  just  above  the  clavicle. 
Although  not  taking  quite  the  same  direction,  yet 
the  posterior  borders  of  the  sterno-mastoid  and 
anterior  scalene  muscles  practically  correspond 
to  one  another. 

Vessels. — The  common  carotid  artery  is  repre- 
sented by  a  line  drawn  from  the  sterno-clavicular 
joint  to  a  point  midway  between  the  angle  of  the 
mandible  and  the  mastoid  process.  The  vessel 
bifurcates  at  the  upper  border  of  the  thyroid  car- 
tilage, or  not  infrequently  nearly  -5  an  inch  above 
that  point.  The  omo-hyoid  crosses  it  opposite  the 
cricoid  cartilage,  and  at  about  the  same  level  the 
artery  is  crossed  by  the  middle  thyroid  vein.  The 
line  of  the  internal  jugular  vein  is  just  external 
to  ( that  for  the  main  artery.  Both  artery  and 
vein  lie  under  the  anterior  border  of  the  sterno- 
mastoid.  The  superior  thyroid  artery  comes  off 
below  the  great  cornu  of  the  hyoid  bone,  and 
curves  forwards  and  downwards  to  the  upper 
edge  of  the  thyroid  cartilage.  The  great  cornu  of 
the  hyoid  serves  as  an  excellent  guide  to  the  lin- 
gual artery,  which  invariably  forms  a  loop  above 
the  posterior  end  of  that  process  before  proceed- 
ing forwards  beneath  the  hyo-glossus  (Fig.  35, 
p.  137).  The  facial  artery  is  very  tortuous,  but  its 
general  course  in  the  neck  is  represented  by  a  line 
drawn  from  the  anterior  border  of  the  masseter 
at  the  lower  border  of  the  mandible  to  a  point 
just  above  the  tip  of  the  great  cornu,  while  the 


176  THE  HEAD    AND   NECK  [CHAP. 

occipital  follows  a  line  that  starts  from  the  latter 
point  and  runs  across  the  base  of  the  mastoid 
process. 

The  external  jugular  vein  follows  a  line  drawn 
from  the  mandibular  angle  to  the  middle  of  the 
clavicle. 

The  subclavian  artery  describes  a  curve  at  the 
root  of  the  neck  (Fig.  44).  One  end  of  the  curve 
corresponds  to  the  sterno-clavicular  joint,  the  other 


VISION  OF  CAROTID 
STERNO- MASTOID 


^SUBCLAV.     ART. 

VERT.  ART. 


Fig.  44. — Diagram  showing  the  surface  markings  for  the 
brachial  plexus,  subclavian  and  carotid  arteries. 

end  to  the  centre  of  the  clavicle,  the  summit  of  the 
curve  rising  to  a  point  about  ^  an  inch  above  that 
bone.  In  the  angle  between  the  posterior  edge 
of  the  sterno-mastoid  and  the  clavicle  the  pulsa- 
tions of  the  artery  may  be  felt.  Just  above  the 
clavicle  the  artery  may  be  compressed  against  the 
first  rib.  The  compression  is  most  easily  applied 
when  the  arm  is  well  drawn  down,  and  the 
direction  of  the  pressure  should  be  downwards 
and  backwards,  for  it  must  not  be  forgotten  that 
the  first  rib  descends  as  it  passes  forwards  under 


ix]  NERVES   OF  THE  NEGK  177 

the  clavicle.  The*  subclavian  vein  lies  below  the 
artery,  and  is  entirely  under  cover  of  the  clavicle. 
The  suprascapular  and  transverse  cervical  arte- 
ries run  parallel  with  the  clavicle,  the  former 
quite  behind  the  bone,  the  latter  just  above  it. 
The  pulsations  of  the  latter  vessel  can  generally 
be  felt. 

Nerves.— The  position  of  the  chief  superficial 
nerves  of  the  neck  may  be  fairly  indicated  by 
six  lines,  all  drawn  from  the  middle  of  the  pos- 
terior border  of  the  sterno-mastoid  muscle.  A  line 
drawn  forwards  from  this  spot  so  as  to  cross 
the  sterno-mastoid  at  right  angles  to  its  long 
axis  corresponds  to  the  superficial  cervical  nerve 
(nervus  cutaneus  colli).  A  second  line  drawn 
up  across  the  muscle  to  the  back  of  the  pinna, 
so  as  to  run  parallel  with  the  external  jugular 
vein,  corresponds  to  the  great  auricular  nerve; 
and  a  third  line,  running  along  the  posterior 
border  of  the  sterno-mastoid  muscle  to  the  scalp, 
marks  the  course  of  the  small  occipital  nerve. 
These  lines,  continued  downwards  so  as  to  cross 
the  sternum,  the  middle  of  the  clavicle,  and  the 
acromion,  will  indicate  respectively  the  anterior, 
middle,  and  posterior  supraclavicular  nerves. 

The  spinal  accessory  nerve  reaches  the  anterior 
border  of  the  sterno-mastoid  muscle  at  a  point 
about  1  inch  below  the  tip  of  the  mastoid  process. 
It  emerges  from  beneath  that  muscle  about  the 
middle  of  its  posterior  border,  crosses  the  pos- 
terior triangle,  and  passes  beneath  the  trapezius 
between  the  middle  and  lower  thirds  of  the  anterior 
border  of  that  muscle  (Fig.  35,  p.  137). 

The  phrenic  nerve  commences  deeply  at  the 
side  of  the  neck,  about  the  level  of  the  mid-point 
of  the  thyroid  cartilage,  and  runs  downwards 
to  a  point  behind  the  sternal  end  of  the  clavicle. 
About  the  level  of  the  cricoid  cartilage  it  lies 
beneath  the  sterno-mastoid  (which  covers  it  whoHy 
in  the  neck)  about  midway  between  the  anterior 
and  posterior  borders  of  the  muscle.  The  brachial 
plexus  can  be  felt,  and  even  seen  in  very  thin 


178  THE  HEAD   AND  NECK  [CHAP. 

subjects.  Its  upper  limits  may  be  represented 
by  a  line  drawn  across  the  side  of  the  neck  from 
a  point  about  opposite  to  the  crico-thyroid  space 
to  a  spot  a  little  external  to  the  centre  of  the 
clavicle  (Fig.  44). 

The  skin  in  the  submandibular  region  is  lax 
and  thin,  and  is  often  found  of  considerable  value 
for  making  flaps  in  plastic  operations  about  the 
mouth.  The  platysma  myoides  is  closely  con- 
nected with  the  skin,  and  to  its  action  is  due  the 
turning-in  of  the  edges  of  such  wounds  as  are 
athwart  the  line  of  direction  of  the  muscle.  The 
amount  of  subcutaneous  fat  in  the  cervical  re- 
gion varies  in  different  parts.  In  the  suprahyoid 
region  it  is  apt  to  undergo  extensive  development, 
producing  the  diffused  lipoma  known  as  "  double- 
chin." 

The  skin  over  the  nape  of  the  neck  is  very 
dense  and  adherent,  and  these  two  circumstances, 
in  addition  to  the  free  nerve  supply  of  the  parts, 
serve  to  explain  the  severe  pain  that  often  accom- 
panies inflammation  in  this  region.  Common  car- 
buncle is  very  often  met  with  here,  at  the  root 
of  the  neck,  in  the  middle  line. 

When  the  steriio-mastoicl  muscle  of  one  side 
is  rigidly  contracted,  either  from  paralysis  of  the 
opposite  muscle  or  from  spasmodic  contraction, 
or  from  some  congenital  defect,  the  condition 
known  as  wry-neck  is  produced.  The  position  of 
the  head  in  wry-neck  illustrates  precisely  ^the 
effect  of  the  sterno-mastoid  when  in  full  action. 
The  head  is  bent  a  little  forwards,  the  chin  is 
turned  towards  the  sound  side,  and  the  ear  on  the 
affected  side  leans  towards  the  sterno-clavicular 
joint.  In  many  cases  the  trapezius  and  splenius 
muscles  are  also  affected.  Spasmodic  contraction 
of  the  muscle  may  be  due  to  reflex  irritation. 
Thus,  it  has  accompanied  inflammation  of  the 
cervical  glands  in  the  posterior  triangle.  Such 
inflammation  has  irritated  some  branches  of  the 
cervical  plexus,  and  the  sterno-mastoid  muscle, 
although  it  is  supplied  mainly  by  the  spinal  acces- 


ix]  WRY-NECK  179 

so ry  nerve,  receives  a  nerve  from  that  plexus  (viz. 
from  the  second  cervical).  The  course  of  the 
reflex  disturbance  in  such  cases  is  therefore  not 
difficult  to  follow.  It  is  to  be  remembered,  too, 
that  the  spinal  accessory  nerve  passes  between  the 
upper  two  or  three  deep  cervical  lymph-glands, 
which  may  compress  it.  A  like  contraction  has 
also  been  produced  by  direct  irritation  of  the 
second  cervical  nerve  in  cases  of  disease  of  the 
first  two  cervical  vertebrae.  For  the  relief  of  some 
forms  of  wry-neck,  the  sterno-mastoid  muscle  is 
divided  subcutaneously,  as  in  an  ordinary  teno- 
tomy  operation,  about  J  an  inch  above  its  attach- 
ment to  the  sternum  and  clavicle.  Two  structures 
stand  considerable  risk  of  being  wounded  in  this 
operation,  viz.  the  external  jugular  vein  lying 
near  the  posterior  border  of  the  muscle,  and  the 
anterior  jugular  which  follows  its  anterior  border 
and  passes  behind  the  muscle,  just  above  the 
clavicle,  to  terminate  in  the  first-named  vein. 
With  common  care,  there  should  be  no  risk  of 
wounding  the  great  vessels  at  the  root  of  the  neck. 
For  spasmodic  wry-neck,  the  spinal  accessory 
nerve  and  the  communicating  branches  of  the 
second  and  third  cervical  nerves  have  been  cut. 
The  spinal  accessory  nerve,  as  already  stated, 
is  found  at  the  anterior  border  of  the  sterno- 
mastoid,  1  inch  below  the  mastoid  process. 

There  is  a  curious  congenital  tumour,  or  in- 
duration, sometimes  met  with  in  this  muscle  in 
the  newly  born.  It  is  usually  ascribed  to  syphilis, 
but,  in  most  cases,  is  probably  due  to  some  tear- 
ing of  the  muscle  fibres  during  the  process  of 
delivery. 

Cervical  fascia. — To  the  connective  tissue 
which  binds  together  the  muscles,  vessels,  nerves, 
and  glands  of  the  neck  the  name  of  cervical 
fascia  is  given.  It  consists  of  the  sheaths  of 
the  muscles,  vessels,  and  nerves.  These  sheaths 
are  united  together  in  such  a  manner  as  to 
allow  free  movements  of  the  oesophagus,  larynx, 
trachea,  and  thyroid  body,  and  yet  to  give  a 


ISO  THE   HEAD   AND  NECK  [CHAP. 

firmness  and  solidity  so  that  the  neck  may  be 
moved  as  a  whole.  Besides  serving  as  a  medium 
for  binding  the  various  structures  of  the  neck 
together,  the  cervical  fascia  forms  the  supporting 
tissue  in  which  the  extensive  lymphatic  system  of 
the  neck  is  embedded  and  conveyed  towards  the 
root  of  the  neck, 

The  deep  cervical  fascia  may  be  divided  into 
(A)  the  superficial  layer,  and  (B)  the  deeper  pro- 
cesses (see  Fig.  45). 

(A)  The  superficial  layer  forms  a  complete 
investment  for  the  neck,  and  covers  in  all  the 
cervical  structures,  except  the  platysma  and  some 
superficial  veins  and  nerves,  with  the  complete- 
ness of  a  perfectly  fitting  cravat.  It  commences 
as  a  thin  layer  behind  at  the  spinous  processes  of 
the  vertebrae,  and,  having  invested  the  trapezius 
muscle,  starts  at  the  anterior  border  of  that 
muscle,  as  a  single  layer,  to  cross  the  posterior 
triangle.  Arriving  at  the  posterior  border  of 
the  sterno-mastoid  muscle,  it  splits  to  enclose 
that  structure,  appearing  again  as  a  single  layer 
at  the  anterior  border  of  the  muscle,  whence  it 
passes  to  the  middle  line  of  the  neck  to  join  the 
fascia  of  the  opposite  side,  entirely  covering  in, 
on  its  way,  the  anterior  triangle.  The  part  that 
occupies  the  posterior  triangle  is  loose  and  open 
in  texture,  and  is  continuous  with  the  connective 
tissue  of  that  triangle.  Over  the  anterior  triangle 
the  fascia  is  attached  above  to  the  lower  border  of 
the  mandible.  Behind  that  bone  it  passes  over  the 
parotid  gland  to  the  zygoma,  forming  the  parotid 
fascia,  while  a  deeper  layer  passes  beneath  the 
gland  (between  it  and  the  submandibular  gland), 
to  be  attached  to  points  at  the  base  of  the  skull. 
It  is  from  this  deeper  part  that  the  stylo-mandi- 
bular  ligament  is  developed.  In  front  the  fascia 
is  attached  to  the  hyoid  bone,  and  just  below  the 
thyroid  body  it  divides  into  two  layers  again,  one 
to  be  attached  to  the  front  of  the  sternum  and  the 
other  to  the  back.  Both  of  these  layers  lie  in  front 
of  the  depressors  of  the  hyoid  bone,  and  they  form 


IX] 


CERVICAL  FASCIA 


181 


between  them  a  little  space  (which  extends  so  far 
laterally  as  to  enclose  the  sternal  head  of  the 
sterno-mastoid),  the  widest  part  9f  which  is  below, 
and  which  there  corresponds  in  width  to  the 
thickness  of  the  sternum.  It  will  be  perceived 
that,  in  dividing  the  sternal  head  of  the  sterno- 
mastoid,  the  operation  is  performed  within  this 
little  chamber  formed  by  the  two  layers  just 


Fig.  45.— Transverse  section  through  the  lower  part  of  the 
neck,  to  show  the  arrangement  of  the  cervical  fascia. 

(Diagrammatic. ) 

a,  Trapezius  ;  b,  sterno-mastoid  ;  c,  depressors  of  hyoid  bone  ;  d,  pla- 
tysma  ;  e,  anterior  spinal  muscles  ;  /,  scalenus  anticus  ;  g,  carotid 
artery  ;  h,  external  jugular  vein  ;  ?',  posterior  spinal  muscles  ; 
T,  trachea,  with  gullet  behind  and  thyroid  body  in  front. 

named,  and  it  is  well  to  note  that  the  anterior 
jugular  vein  also  occupies  this  chamber  on  its  way 
to  the  external  jugular  trunk. 

(B)  The  deeper  processes.— (1)  From  the  super- 
ficial layer  a  process  comes  off  near  the  anterior 
border  of  the  sterno-mastoid  muscles,  which,  passing 


182  THE   HEAD   AND  NECK  [CHAP. 

beneath  the  depressors  of  the  hyoid  bone,  invests 
the  thyroid  body  and  front  of  the  trachea,  and 
runs  down,  in  front  of  that  tube  and  of  the 
large  vessels,  to  the  fibrous  layer  of  the  peri- 
cardium. (2)  The  prevertebral  fascia  is  a  layer 
that  descends  on  the  prevertebral  muscles  behind 
the  pharynx  and  gullet.  It  is  attached  above 
to  the  base  of  the  skull,  and,  below,  descends  into 
the  thorax,  behind  the  oesophagus.  Laterally,  it 
joins  the  carotid  sheath,  and  is  then  prolonged 
outwards  and  downwards  over  the  scalene  muscles, 
the  brachial  plexus,  and  the  subclavian  vessels.  It 
follows  these  vessels  beneath  the  clavicle,  where 
it  forms  the  axillary  sheath  and  becomes  con- 
nected with  the  under  surfa.ce  of  the  costo-cora- 
coid  membrane.  (3)  The  sheath  of  the  carotid 
artery  and  its  accompanying  vein  and  nerve  is 
continuous  with  the  prevertebral  and  pretracheal 
layers  and  with  the  sheath  of  the  sterno-mastoid 
(Fig.  45).  The  carotid  sheath  descends  with  the  pre- 
tracheal layer,  to  end  in  the  sheath  of  the  aorta 
and  pericardium.  Hence,  in  a  sense,  the  heart 
and  pericardium  are  supported  from  the  neck; 
when  the  head  is  thrown  back  the  carotid  sheaths 
become  tense  and  the  thoracic  structures  are 
lifted  upwards. 

In  many  cases  a  cervical  abscess  has  burst  into 
the  gullet^  or  trachea,  and  even  into  the  pleura. 
In  some  instances  the  great  vessels  have  been 
opened  up.  In  one  remarkable  case  reported  by 
Savory  (Med.-Ghir.  Trans.,  1881),  not  only  was 
a  considerable  portion  of  the  common  carotid 
artery  destroyed  by  the  abscess,  but  also  a  still 
larger  portion  of  the  internal  jugular  vein  and  a 
large  part  of  the  vagus  nerve.  This,  and  like 
examples  of  the  destructive  action  of  some  cervical 
abscesses,  depend,  no  doubt,  upon  the  unyielding 
character  of  the  cervical  fascia,  which  hems  in 
the  pus  on  all  sides,  and  drives  it  to  resort  to 
desperate  measures  to  effect  an  escape.  "It  is 
noteworthy,"  remarks  Jacobson,  "that  communi- 
cations between  abscesses  and  deep  vessels  have 


ix]  CERVICAL  RIBS  183 

usually  taken  place  beneath  two  of  the  strongest 
fasciae  in  the  body,  the  deep  cervical  fascia  and 
the  fascia  lata"  (Hilton's  "Rest  and  Pain"). 

The  apex  of  the  hm$r  extends  into  the 
neck,  and  reaches  a  point  from  1  to  2  inches 
above  the  inner  half  of  the  clavicle.  A  point 
between  the  sternal  and  clavicular  heads  of  the 
sterno-mastoid  and  1|  inches  above  the  clavicle 
will,  in  the  majority  of  adults,  mark  the  highest 
point  of  the  apex  and  the  position  of  the  neck  of 
the  first  rib.  It  lies  behind  the  clavicle,  anterior 
scalene  muscle,  and  subclavian  vessels.  The  right 
lung  commonly  extends  higher  up  than  the  left. 

The  pleura  has  been  opened  in  careless  opera- 
tions on  the  subclavian  artery,  and  has  also  been 
torn  in  dragging  deep-seated  tumours  from  the 
base  of  the  neck.  The  pleura  and  lung  have  been 
wounded  in  stabs  of  the  neck  and  by  fragments 
of  bone  in  severe  fractures  of  the  clavicle.  Cer- 
vical abscesses  have  opened  into  the  pleura,  and, 
apart  from  this,  pleurisy  has  followed  inflamma- 
tion of  the  cellular  tissue  at  the  root  of  the  neck. 
Sibson's  fascia,  which  is  attached  along  the  inner 
border  of  the  first  rib,  strengthens  the  pleura  over 
the  apex  of  the  lung. 

Cervical  ribs. — These  structures  have  led  to 
many  errors  in  diagnosis,  have  been  mistaken  for 
exostoses,  and,  where  the  subclavian  artery  is  car- 
ried over  them,  which  is  usually  the  case  (Fig.  46), 
have  led  to  the  diagnosis  of  aneurysm.  They  are 
met  with  in  from  1  to  2  per  cent,  of  all  individuals, 
but  rarely  give  rise  to  symptoms  until  adult  years 
are  reached.  They  represent  the  ribs  which  are 
normally  developed  in  some  lower  vertebrates. 
In  most  cases  a  cervical  rib  is  found  on  either  .side 
of  the  seventh  ^cervical  vertebra;  sometimes  it  is 
movable,  sometimes  it  is  ankylosed  to  the  vertebra 
and  its  transverse  process.  A  rudiment  is  always 
present  in  the  foetus.  It  may  be  very  short,  and 
represented  only  by  a  head,  neck,  and  tubercle. 
Such  forms  have  been  mistaken  for  exostoses. 
It  may  be  long,  and  may  then  end  free,  or  be 


184 


THE  HEAD  AND  NEGK 


[CHAP. 


joined  to  the  first  rib  or  the  first  costal  cartilage 
by  ligament,  or  even  by  cartilage.  In  such  in- 
stances the  subclavian  artery  passes  over  the 
cervical  rib,  its  pulsations  being  very  distinctly 
seen  and  felt.  To  the  longer  form  of  cervical  ribs 
the  scalenus  anticus  and  the  scalenus  medius 


FIFTH  CERV./IECVE 


[CAROTID  TUBERCLE 

IJ.TRACMEA 
4.EICMTM  CERV./IECVE 
CERVICAL  RIB 
ART 


E+CAROTID  ART. 

5iBSOM's  FASCIA 
ART. 


^CLAVICLE 


Fig.  46.  — Showing  the  relationship  of  the  subclavian  artery 
and  brachial  plexus  to  a  cervical  rib. 

may  be  attached.  Occasionally  subjects  of  this 
anomaly  complain  of  numbness  along  the  ulnar 
side  of  the  arm  and  hand,  or  of  partial  paralysis 
of  the  muscles  of  the  hand.  These  symptoms  are 
due  to  traction  on  the  first  dorsal  nerve  at  the 
point  where  it  crosses  above  the  cervical  rib 
(Thorburn).  {See  Fig.  46.)  Cervical  ribs  with 


ix]  WOUNDS   OF   THE   NEGK  185 

associated  pressure  symptoms  may  be  traced 
through  several  generations  of  the  same  family 
(Theodore  Thompson).  In  thin  subjects  the  rib 
can  be  seen  as  a  distinct  projection  in  the 
neck.  Prof.  Wood- Jones  has  pointed  out  that 
the  groove  on  the  upper  surface  of  the  first  rib 
is  occupied,  when  the  arm  hangs  by  the  side, 
uot  by  the  subclavian  artery  but  by  the  lowest 
trunk  of  the  brachial  plexus  formed  by  the  eighth 
cervical  and  first  dorsal  nerves.  He  has  also 
shown  that  the  groove  is  deepest,  and  the  pres- 
sure between  the  nerve  trunk  and  rib  therefore 
greatest,  in  those  cases  where  a  considerable  part 
of  the  second  dorsal  nerve  enters  into  the  forma- 
tion of  the  lowest  trunk  of  the  brachial  plexus. 

4  Hi  throat  and  wounds  of  the  neck. — 
The  skin  of  the  neck  is  so  elastic  and  mobile  that 
it  is  readily  thrown  into  folds  when  a  knife, 
and  especially  a  blunt  knife,  is  drawn  across  it. 
Thus  in  cases  of  cut  throat  several  distinct  skin- 
cuts  may  be  found  that  were  all  produced  by  one 
movement  of  the  knife.  The  wound  in  cut  throat, 
whether  suicidal  or  homicidal,  most  frequently 
involves  the  thyro-hyoid  membrane,  next  in  fre- 
quency the  trachea,  and  then  the  thyroid  car- 
tilage. (See  Fig.  44,  p.  17G.) 

1.  If  the  wound  be  above  the  hyoid  bone  the 
following   parts   may   be   cut :    Anterior   jugular 
vein ;    anterior    belly    of    digastric ;    mylo-hyoid, 
genio-hyoid,    genio-glossus,    and   hyo-glossus  mus- 
cles;  the   lingual  artery;   branches  of  the  facial 
artery;     the    hypoglossal     and     lingual     nerves; 
the  submandibular  gland.     The  substance  of  the 
tongue  may  be  cut,   and  the  floor  of  the  mouth 
freely  opened.     In  any  case  where  the  attachments 
of  the  tongue  are  divided  the  organ  is  apt  to  fall 
back  upon  the  larynx  and  produce  suffocation. 

2.  If   the    wound    be  across  the  thyro  -  hyoid 
space  the  following  may  be  the  parts  cut:   Ante- 
rior jugular  vein;  sterno-hyoid,  thyro-hyoid,  omo- 
hyoid   muscles;   thyro-hyoid   membrane;    inferior 
constrictor;    superior    laryngeal    nerve;    superior 


186  THE   HEAD  AND  NECK  [CHAP. 

thyroid  artery;  and  if  it  be  near  the  hyoid  bone 
the  trunk  of  the  lingual  artery  may  be  cut.  The 
pharynx  would  be  opened  in  a  deep  wound,  and 
the  epiglottis  divided  near  its  base.  Division  of 
the  epiglottis  in  wounds  in  this  situation  is  always 
a  serious  complication. 

3.  If  the  wound  involve  the  trachea  the  follow- 
ing may  be  the  parts  cut :  Anterior  jugular 
vein ;  sterno-hyoid,  sterno-thyroid,  and  omo-hyoid 
muscles ;  part  of  sterno-mastoid ;  thyroid  gland ; 
superior  and  inferior  thyroid  arteries;  superior, 
middle,  and  inferior  thyroid  veins;  recurrent 
laryngeal  nerves  and  the  gullet. 

In  wounds  of  the  neck  the  great  vessels  often 
escape  in  a  marvellous  manner.  They  are  pro- 
tected in  part  by  the  depth  at  which  they  are 
situated,  and  in  part  by  their  great  mobility, 
lying  as  they  do  in  an  environment  of  loose  con- 
nective tissue.  Dieffenbach  relates  a  case  of  cut 
throat  in  which  both  gullet  and  trachea  were 
divided  without  any  damage  to  the  great  vessels. 
In  cut  throat  the  vessels  are  greatly  protected 
by  the  projecting  thyroid  cartilage  above  and  by 
the  contracting  of  the  sterno-mastoid  muscles 
below.  Deep  gashes  made  across  the  crico-thy- 
roid  space,  or  through  the  upper  part  of  the 
trachea,  reach  the  great  vessels  more  easily  than 
wounds  made  with  equal  force  in  any  other  part 
of  the  neck. 

In  some  cases  of  gunshot  wound  the  vessels 
seem  to  have  been  actually  pushed  aside,  and  to 
have  owed  their  safety  to  their  mobility.  Thus, 
in  a  case  reported  by  Longmore,  the  bullet  passed 
entirely  through  the  neck  from  one  side  to  the 
other.  It  passed  through  the  gullet,  damaged  the 
posterior  part  of  the  larynx,  but  left  the  great 
vessels  intact.  In  another  recorded  case  a  boy 
fell  upon  the  point  of  a  walking-stick.  The  end 
of  the  stick  passed  entirely  through  the  neck 
from  side  to  side,  entering  in  front  of  one  sterno- 
mastoid  muscle  and  emerging  through  the  sub- 
stance of  the  opposite  one.  It  probably  passed 


ix]        FRACTURE   OF   THE   HYOID   BONE        187 

between  the  pharynx  and  the  spine.  The  boy. 
who  left  the  hospital  well  in  eighteen  days,  owed 
his  safety  to  the  laxity  of  the  cervical  connective 
tissue  and  to  the  mobility  of  the  main  structures 
in  the  neck.  The  structures  of  the  neck  are  fixed 
laxly  to  allow  movements  of  the  larynx  and 
tongue. 

In  connexion  with  the  subject  of  wounds  of  the 
neck,  it  must  be  remembered  that  the  most  im- 
portant part  of  the  spinal  cord  can  be  reached 
from  behind,  through  the  gap  between  the  atlas 
and  axis.  In  this  situation  the  cord  has  been 
divided  by  one  stab  of  a  knife,  the  instrument 
entering  between  the  two  bones.  Langier  gives 
some  ingenious  cases  of  infanticide  where  the 
lethal  weapon  was  merely  a  long  needle.  The 
needle  was  introduced  into  the  spinal  canal  be- 
tween the  atlas  and  the  axis,  and  the  cord  readily 
cut  across. 

The  Iiyoid  bone  may  be  broken  by  direct  vio- 
lence, as  from  blows,  or  in  the  act  of  throttling. 
It  is  sometimes  found  broken  in  those  who  have 
been  hanged.  The  fracture  may  involve  the  body 
of  the  bone,  but  more  usually  the  greater  cornu 
is  found  broken  off.  In  the  New  York  Medical 
Record  (1882)  is  published  the  leport  of  the  case 
of  a  man  who  felt  something  snap  under  his  chin 
while  yawning.  On  examination  the  hyoid  bone 
was  found  to  be  fractured.  The  bone  was  also 
found  broken  in  a  patient  who  threw  her  head 
violent!  v  backwards  to  save  herself  from  fall- 
ing (Hamilton).  The  fracture  is  associated  with 
great  difficulty  and  pain  in  speaking,  ^  in  moving 
the  tongue,  in  opening  the  mouth,  and  in  swallow- 
ing— symptoms  that  may  be  readily  understood. 
A  bursa  lies  between  the  thyro-hypid  membrane 
and  the  posterior  surface  of  the  hyoid  bone.  When 
enlarged,  it  may  form  one  of  the  cystic  tumours 
of  the  neck. 

i  aryn*  mid  trachea.— The  position  of  the 
larynx  in  the  neck  is  influenced  by  age.  In  the 
adult  the  cricoid  cartilage  reaches  to  the  lower 


188  THE   HEAD   AND  NECK  [CHAP, 

part  of  the  sixth  cervical  vertebra.  In  a  child 
of  three  months  it  reaches  the  lower  border  of 
the  fourth  cervical,  and  in  a  child  of  six  years 
the  lower  border  of  the  fifth  vertebra.  At  puberty 
it  attains  the  adult  position.  The  upper  end  of 
the  epiglottis  in  the  adult  is  opposite  the  lower 
border  of  the  third  cervical  vertebra.  With  the 
laryngoscope  the  following  parts  may  be  made 
out  (Fig.  47)  :  The  base  of  the  tongue  and  the 
glosso-epiglottic  folds;  the  superior  aperture  of 
the  larynx,  presenting  in  front  the  epiglottis, 
the  cushion  of  the  epiglottis  (Fig.  47,  A),  at  the 
sides  the  aryteno-epiglottidean  folds  (in  which 
are  two  rounded  eminences  corresponding  to 
the  cornicula  and  cuneiform  cartilages),  and  at 
the  back  the  arytenoid  commissure  of  mucous 
membrane.  Deep  down  can  be  seen  the  true  and 
false  vocal  cords,  the  ventricle,  the  anterior  wall 
of  the  larynx,  a  little  of  the  cricoid  cartilage, 
and  more  or  less  of  the  anterior  wall  of  the 
trachea.  If  the  glottis  be  very  fully  dilated 
the  openings  of  the  two  bronchi  may  be  dimly 
seen. 

The  thyroid  and  cricoid  cartilages  and  the 
greater  part  of  the  arytenoid  are  in  structure 
hyaline,  as  are  the  costal  cartilages.  Like  the 
last-named,  they  are  liable  to  become  more  or  less 
ossified  as  life  advances.  Ossification  commences 
in  the  thyroid  and  cricoid  cartilages  at  about 
the  age  of  20,  and  in  either  cartilage  the  process 
commences  in  the  vicinity  of  the  crico-thyrpid 
joint.  The  arytenoid  ossifies  later.  Ossification 
of  the  laryngeal  cartilages  is  more  marked  in 
males  than  in  females.  The  larger  cartilages  are 
liable  to  be  fractured  by  violence,  as  by  blows, 
throttling,  etc.  The  thyroid  is  the  one  most  fre- 
quently broken,  and  usually  in  the  median  line. 
The  posterior  superior  angle  of  the  thyroid  car- 
tilage marks  the  position  of  the  pyriform  fossa, 
a  wide  recess,  above  and  external  to  the  aryteno- 
epiglottic  folds  (Fig.  47).  Foreign  bodies  may 
be  arrested  in  this  fossa. 


IX] 


RIMA  GLOTTIDIS 


189 


The  riraa  glottidis  is  the  aperture  between  the 
true  vocal  cords  and  the  vocal  process  of  the  aryte- 
noid  cartilages,  to  which  the  cords  are  attached 
posteriorly.  The  cords  are  double  the  length  of 
the  processes,  and  are  of  a  grey-buff  colour,  owing 
to  the  elastic  tissue,  of  which  they  are  mainly 
composed,  being  apparent  beneath  the  stratified 
epithelium.  The  rima  is  the  narrowest  part  of 
the  interior  of  the  larynx,  and  it  is  well  to  be 
familiar  with  its  proportions  in  reference  to  the 


i  2 

Fig.  47.— Upper  aperture  of  the  larynx  in  the  open  (1)  and 
shut  (2)  positions. 

JL,  Cushion  of  epiglottis  ;  B,  apices  of  arytenoids ;  c,  aryteno-epi- 
glottidean  folds :  E.  posterior  aspect  of  cricoid ;  F,  false  vocal 
cords  ;  G,  rima  glottidis,  between  true  vocal  cords  ;  H,  posterior 
border  of  thyroid  cartilage  ;  I,  tip  of  great  horn  of  hyoid. 

entrance  of  foreign  bodies  and  the  introduction 
of  instruments.  In  the  adult  male  the  rima  mea- 
sures nearly  1  inch  (23  mm.)  from  before  back- 
wards ;  f roin  side  to  side,  at  its  widest  part,  it 
measures  about  one-third  of  the  length;  this  dia- 
meter may  be  increased  to  one-half  of  the  length 
in  extreme  dilatation.  In  the  female  and  in  the 
male  before  puberty  the  antero-posterior  diameter 
is  from  17  mrn^  The  rima  is  widely  opened  dur- 
ing inspiration,  owing  to  the  action  of  the  crico- 
arytenoideus  posticus,  while  the  vocal  cords  are 


190  THE   HEAD   AND  NECK  [CHAP. 

approximated  in  speech  under  the  influence  of  the 
crico-arytenoideus  lateralis  (Fig.   48). 

The  mucous  membrane  of  the  larynx  varies 
in  thickness  in  different  parts,  and  in  the  amount 
of  its  submucous  tissue.  The  membrane  is  thick- 
est, and  the  submucous  tissue  most  abundant,  in 
the  following  parts,  taken  in  order  of  degree: 
the  aryteno-epiglottidean  folds,  the  mucous  mem- 
brane of  the  ventricle,  the  ventricular  folds 
(false  vocal  cords),  and  the  laryngeal  aspect  of 
the  epiglottis.  These  are  the  parts  that  become 


!NF.  CONSTRICT. 

AftYTEMOID    MUSCLE 


-EPIGLOT.FOLD 
HT.-AKYTEN  .  FOLD 


ARYTENOIP    CARTILAGE  L£-F-r  COffO  (pAR 


Fig.  48.  —  A,  Coronal  vertical  section  of  the  larynx, 
showing  the  vocal  cords,  ventricles,  ventricular  folds, 
and  thyro  -  arytenoid  muscles  ;  B,  the  rima  glottidis 
seen  from  above,  with  the  left  cord  in  the  position 
of  adductor  paralysis,  and  the  muscles  which  move 
the  arytenoid  cartilages  indicated  on  the  right. 

most  congested  and  swollen  in  acute  laryn- 
gitis ;  and  the  serious  condition  known  as  oedema 
of  the  glottis  depends  mainly  upon  effusion 
into  the  lax  submucous  tissue  in  the  aryteno- 
epiglottidean  folds.  The  lax  condition  of  the 
mucous  membrane  of  the  aryteno-epiglottidean 
folds  allows  free  movements  of  the  arytenoid 
cartilages  and  complete  closure  of  the  upper 
aperture  of  the  larynx  (Fig.  47).  The  mucous 
membrane  is  firmly  bound  to  the  true  vocal  cords 
and  covered  by  stratified  epithelium,  while  the 


ix]  DYSPHONIA  CLERIGORUM  191 

rest  of  the  larynx  is  lined,  like  the  trachea,  with 
ciliated  epithelium.  Owing  to  the  nature  of  its 
covering  and  exposure  to  friction,  the  true  vocal 
cord  is  not  an  uncommon  site  of  epithelioma. 
The  affection  known  as  "  clergyman's  sore  throat ''" 
has  an  interesting  anatomical  basis.  The  mucous 
membrane  of  the  larynx  is  well  provided  with 
mucous  glands,  whose  function  it  is  to  keep  moist 
the  parts  concerned  in  phonation.  When  an  in- 
dividual speaks  aloud  for  a  long  time  the  lining 
of  the  larynx  tends  to  become  dry,  on  account 
of  the  large  amount  of  cold  air  that  is  drawn 
in  directly  through  the  mouth.  To  keep  these 
parts  moist  the  mucous  glands  have  to  exhibit 
increased  energy,  and  in  those  who  speak  much 
in  public  the  glands  may  in  time  become  so  over- 
worked as  to  inflame.  It  is  the  inflammation 
of  these  glands  that  constitutes  the  present  affec- 
tion. The  glands  are  not  distributed  equally  over 
all  parts  of  the  larynx,  but  are  most  numerous 
in  the  membrane  covering  the  arytenoid  cartilages 
and  parts  immediately  about  them,  the  base  of 
the  epiglottis,  and  the  interior  of  the  ventricle. 
It  is  in  these  parts,  therefore,  that  the  changes 
in  chronic  glandular  laryngitis,  or  dysphonia 
clericorum,  are  most  marked. 

Excision  of  the  larynx. — The  entire  larynx  has 
been  removed  for  carcinomatous  disease,  but  the 
operation,  although  not  immediately  fatal,  has 
not  been  followed  by  very  satisfactory  results.. 
It  is  removed  through  an  incision  in  the  middle 
line.  In  this  incision  are  divided  the  platysma, 
the  fascia,  and  the  anterior  jugular  vein.  The 
larynx  is  separated  from  its  connexions,  the  fol- 
lowing structures  being  divided  :  sterno-thyroid, 
thyro-hyoid,  stylo-pharyngeus,  palato-pharyngeus, 
and  inferior  constrictor  muscles,  the  laryngeal 
branches  of  the  superior  and  inferior  thyroid  arte- 
ries, the  superior  and  inferior  laryngeal  nerves, 
the  hyo-epiglpttic  and  glosso-epiglottic  ligaments. 
The  larynx  is  then  separated  from  the  trachea, 
and  is  dissected  off  from  below  up.  In  separating 


192  THE  HEAD  AND   NECK  [CHAP. 

gullet  and  pharynx  there  is  great  risk  of  "  button- 
holing "  the  former  tube.  Growths  and  foreign 
bodies  may  be  removed  from  the  larynx  by  the 
operation  of  thyrotomy :  the  two  alas  of  the  thyroid 
are  separated  along  the  middle  line  and  pulled 
apart,  thus  exposing  the  interior  of  the  larynx. 
In  subjects  over  45  years  of  age  the  cartilage  be- 
comes ossified  in  the  middle  line,  and  will  require 
division  by  a  fine  saw.  It  should  be  remembered 
that  the  vocal  cords  are  attached  on  each  side  of 
the  median  line  near  the  mid-point  of  the  anterior 
border  of  the  thyroid  cartilage,  while  just  above 
them  are  fixed  the  ventricular  folds  or  false  vocal 
cords  and  stalk  of  the  epiglottis. 

The  lymphatic  vessels  of  the  upper  half  of  the 
larynx  follow  the  superior  laryngeal  vessels  and 
pass  to  the  upper  deep  cervical  glands.  A  small 
lymphatic  gland,  the  first  to  become  the  seat  of 
secondary  cancerous  deposit,  is  situated  below 
the  horn  of  the  hyoid  on  the  thyro-hyoid  mem- 
brane (Fig.  50,  p.  207).  The  lymphatics  of  the 
lower  half  of  the  larynx  accompany  the  inferior 
thyroid  vessels  and  pass  through  lymph-glands  by 
the  side  of  the  trachea. 

Tracheotomy  and  laryngotomy. — The  trachea 
measures  about  4j  inches  in  length,  and  from  f 
to  1  inch  in  its  extreme  width.  It  is  surrounded 
by  an  atmosphere  of  very  lax  connective  tissue, 
which  allows  a  considerable  degree  of  mobility  to 
the  tube.  The  mobility  of  the  trachea  is  greater 
in  children  than  in  adults,  and  adds  much  to  the 
difficulties  of  tracheotomy.  In  this  procedure  the 
windpipe  is  opened  in  the  middle  line  by  cutting 
two  or  three  of  its  rings  above,  below,  or  through 
the  isthmus  of  the  thyroid  gland.  Since  the 
trachea,  as  it  descends,  lies  farther  from  the  sur- 
face, and  comes  in  relation  with  more  and  moro 
important  structures,  it  is  obvious  that,  other 
things  being  equal,  the  higher  in  the  neck  the 
operation  can  be  done  the  better.  The  length  of 
trachea  in  the  neck  is  not  so  considerable  as 
might  at  first  appear,  and,  according  to  Holden, 


ix]  TRACHEOTOMY  193 

not  more  than  some  seven  or  eight  of  the  tracheal 
rings  (which  number  sixteen  to  twenty  in  all)  are 
usually  to  be  found  above  the  sternum.  The  dis- 
tance between  the  cricoid  cartilage  and  the  sternal 
notch  varies  greatly,  and  depends  upon  the  length 
of  the  neck,  the  age  of  the  patient,  and  the  posi- 
tion of  the  head.  If  2  inches  of  trachea  are  ex- 
posed above  the  sternum  when  the  head  rests  easily 
upon  the  spine,  then  in  full  extension  of  the  head 
some  |  of  an  inch  more  of  the  windpipe  will,  as 
it  were,  be  drawn  up  into  the  neck.  According 
to  Tillaux,  the  average  full  distance  between  the 
cricoid  cartilage  and  the  sternum  is,  in  the  adult, 
about  2f  inches  (7  cm.).  The  full  distance  in  a 
child  between  3  and  5  years  is  about  1^  inches 
(4  cm.),  in  a  child  between  6  and  7  years 
about  2  inches  (5  cm.),  and  in  children  between 
8  and  10  years  about  Z^  inches  (6  cm.).  As 
may  be  imagined,  the  dimensions  of  the  trachea 
on  section  vary  greatly  at  different  ages,  and  even 
in  different  individuals  of  the  same  age.  This 
leads  to  the  question  as  to  the  proper  diameter 
of  tracheotomy  tubes.  Guersant,  who  has  paid 
much  attention  to  this  matter,  says  that  the  dia- 
meter of  the  tubes  should  run  from  6  mm.  to 
15  mm.*  The  tubes  with  a  diameter  of  from 
12  mm.  to  15  mm.  are  for  adults.  For  children 
under  18  months  the  diameter  of  the  tube  should 
be  about  4  mm. 

In  performing  tracheotomy  it  is  most  im- 
portant that  the  head  be  thrown  as  far  back  as 
possible,  and  that  the  chin  be  kept  strictly  in  a 
line  with  the  sternal  notch,  so  that  the  relations 
of  the  jniddle  line  of  the  neck  be  preserved.  Full 
extension  of  the  head  not  only  gives  the  surgeon 
increased  room  for  the  operation,  but  also  brings 
the  trachea  nearer  to  the  surface,  and  by  stretch- 
ing the  tube  renders  it  much  less  mobile. 

In  cutting  down  upon  the  trachea  in  the 
middle  line  of  the  neck  from  the  cricoid  cartilage 

*  The  reader    may   be  reminded   that  12';j    mm.  =  about  i  in.,  and 
6  mm.  therefore  =  about  \  in. 
H 


194  THE    HEAD    AND    NECK  CHAP, 

to  the  sternum  the  following  parts  are  met  with  : 
Beneath  the  integument  lie  the  anterior  jugular 
veins.  As  a  rule  these  veins  lie  some  little  way 
apart  on  either  side  of  the  median  line,  and  do 
not  communicate  except  by  a  large  transverse 
branch  which  lies  in  the  interfascial  space  at  the 
upper  border  of  the  sternum.  Sometimes  there 
are  many  communicating  branches  right  in  front 
of  the  tracheotomy  district,  or  the  veins  may 
form  almost  a  plexus  in  front  of  the  trachea,  or 
there  may  be  a  single  vein  which  will  follow  the 
middle  line.  Then  comes  the  cervical  fascia, 
enclosing  the  sterno-hyoid  and  sterno-thyroid 
muscles.  The  gap  between  the  muscles  of  opposite 
sides  is  lozenge-shaped,  and  is  such  that  the 
trachea  can  be  exposed  without  dividing  muscle 
fibres.  The  isthmus  of  the  thyroid  usually  crosses 
the  second,  third,  and  fourth  rings  of  the  trachea. 
Above  it  a  transverse  communicating  branch  be- 
tween the  superior  thyroid  veins  is  sometimes 
found.  Over  the  isthmus  is  a  venous  plexus,  from 
which  the  inferior  thyroid  veins  arise,  while  be- 
low the  isthmus  these  veins  lie  in  front  of  the 
trachea  together  with  the  thyroidea  ima  artery 
(when  it  exists).  The  inferior  thyroid  vein  may 
be  represented  by  a  single  trunk  occupying  the 
middle  line.  In  the  infant  before  the  age  of 
2  years  the  thymus  extends  up  for  a  variable 
distance  in  front  of  the  trachea.  At  the  very  root 
of  the  neck  the  trachea  is  crossed  by  the  innomi- 
nate and  left  carotid  arteries  and  by  the  left 
innominate  vein;  and  lastly,  abnormal  branches 
of  the  superior  thyroid  artery  may  cross  the 
upper  rings  of  the  windpipe. 

The  evil  of  wounding  the  thyroid  isthmus  is 
exaggerated.  I  (F.  T.)  have  frequently  divided 
this  structure  in  performing  tracheotomy,  without 
any  inconvenience  resulting.  Like  other  median 
raphes,  the  middle  line  of  the  thyroid  isthmus  has 
but  &  slight  v-ascularity,  and  it  has  been  shown 
that  one  side  of  the  thyroid  gland  can  only  be  par- 
tially injected  from  the  other  (i.e.  by  injection  that 


ix]  ,      LARYNGOTOMY  195 

crosses  the  isthmus).  The  difficulty  of  tracheotomy 
in  infants  depends  upon  the  shortness  of  the 
neck,  the  amount  of  the  subcutaneous  fat,  the 
depth  at  which  the  trachea  lies,  its  small  size,  its 
great  mobility,  and  the  ease  with  which  it  can  be 
made  to  collapse  on  pressure.  To  the  finger, 
roughly  introduced,  the  infant's  trachea  offers 
little  resistance.  Its  mobility  is  such  that  we 
hear  of  its  being  held  aside  unknowingly  by  re- 
tractors while  the  operator  is  scoring  the  oeso- 
phagus (Durham).  In  the  child,  too,  the  great 
vessels  often  cross  the  trachea  higher  up  than  in 
the  adult,  and  some  inconvenience  may  also  arise 
from  an  unduly  prominent  thymus.  In  one  case, 
in  an  infant,  the  end  of  a  tracheotomy  tube  press- 
ing on  the  front  of  the  trachea  produced  an  ulcer 
that  opened  the  innominate  artery  (Brit.  Med. 
Journ.,  1885).  In  introducing  the  cannula,  if  the 
tracheal  wound  be  missed,  it  is  easy  to  thrust 
the  instrument  into  the  lax  tissue  beneath  the 
cervical  fascia  and  imagine  that  it  is  within 
the  windpipe. 

In  laryngotomy  the  air-passage  is  opened  by 
a  transverse  cut  through  the  crico-thyroid  mem- 
brane. The  crico-thyroid  space  only  measures 
about  \  an  inch  in  vertical  height  in  well-, 
developed  adult  subjects,  while  in  children  it  is 
much  too  small  to  allow  of  a  cannula  being  in- 
troduced. The  crico-thyroid  arteries  cross  the 
space,  and  can  hardly  escape  division.  They  are, 
as  a  rule,  of  very  insignificant  size,  and  give 
no  trouble.  Occasionally,  however,  these  vessels 
are  large,  and  "cases  are  recorded  in  which 
serious  and  even  fatal  haemorrhage  has  occurred 
from  these  vessels  "  (Durham).  In  introducing  the 
cannula  it  may  readily  slip  between  the  crico- 
thyroid  membrane  and  the  mucous  lining  instead 
of  entering  the  trachea. 

Foreign  bodies  often  find  their  way  into  the 
air-passages,  and  they  have  been  represented  by 
articles  of  food,  teeth,  pills,  buttons,  small  stones, 
and  the  like.  They  are  usually  inspired  during 


196  THE    HEAD    AND    NECK  [CHAP, 

the  act  of  respiration,  and  may  lodge  in  the 
superior  aperture  of  the  larynx,  or  in  the  rima, 
or  find  their  way  into  the  ventricle,  or  lodge  in 
the  trachea,  or  enter  a  bronchus.  If  a  foreign 
substance  enters  a  bronchus  it  usually  selects 
the  right,  that  bronchus  having  its  aperture  more 
immediately  under  the  centre  of  the  trachea  than 
has  the  left  tube.  On  one  occasion,  in  a  dissecting- 
room  subject,  I  (F.  T.)  found  two  threepenny  pieces 
lying  side  by  side,  in  the  right  bronchus,  so  as 
entirely  to  block  the  tube.  The  danger  of  inhaled 
foreign  substances  depends  not  so  much  upon  the 
mechanical  obstruction  they  offer  as  upon  the 
spasm  of  the  glottis  they  excite  by  reflex  irrita- 
tion. A  body  may,  however,  lodge  in  the  ventricle 
for  some  time  without  causing  much  trouble,  as 
in  a  case  reported  by  Desault,  where  a  cherry- 
stone lodged  for  two  years  in  this  cavity  without 
much  inconvenience  to  its  host.  In  one  strange 
case  a  bronchial  gland  found  its  way  into  the 
trachea  by  producing  ulcer ation  of  that  tube,  was 
coughed  up,  and  became  impacted  in  the  rima 
glottidis.  The  patient  was  saved  from  immediate 
suffocation  by  tracheotomy. 

Thyroid  body. — Each  lobe  of  this  body  should 
measure  about  2  inches ^ in  length^  l£  inches  in 
breadth,  and  f  of  an  inch  in  thickness  at  its 
largest  part.  When  distinctly  beyond  these  mea- 
surements the  thyroid  may  be  considered  to  be 
enlarged.  Its  usual  weight  is  between  1  and 
2  oz.  Of  the  three  surfaces  (Fig.  49),  the  anterior 
is  covered  by  the  infrahyoid  muscles,  its  inner 
rests  on  the  larynx  and  trachea,  while  its  outer 
or  posterior  covers  the  carotid  sheath.  Its  promi- 
nent posterior  border  is  in  contact  at  its  lower 
part  with  the  recurrent  laryngeal  nerve  and 
oesophagus.  Each  lobe  extends  from  about  the 
middle  of  the  thyroid  cartilage  to  the  sixth  ring 
of  the  trachea.  It  is  larger  in  females  than  in 
males,  and  the  right  lobe  is  usually  larger  than 
the  left.  In  connexion  with  these  matters  it  may 
be  noted  that  thyroid  enlargements  (bronchocolo, 


IX] 


THYKO1D  GLAND 


197 


goitre)  are  more  common  in  females  than  in 
males,  and  in  any  case  are  more  apt  to  be  first 
noticed  on  the  right  side.  The  body  being  closely 
adherent  to  the  trachea  and  larynx,  it  follows 
that  it  moves  up  and  down  during  deglutition, 
and  this  circumstance  is  of  the  utmost  value  in 
the  diagnosis  of  bronchocele  from  other  cervical 
tumours.  A  strong  process  of  cervical  fascia  (the 
suspensory  ligament  of  Berry)  binds  the  gland  to 
each  side  of  the  cricoid  cartilage,  and  has  to  be 
severed  before  complete  removal  is  possible.  The 


ANT.   JUG.   VEIN 
\ 


TRACHEA 


STERNO-HYOID 

STERNO-THYROIO 

STERNO-MASTOlD 


JUQ.  VEIN 
CAROTID  ART. 
RECURRENT  LARYNQ. 

TRACHEA      / 
OESOPHAGUS 


OMO-HYOID 
INF.  THYROID  ART. 
VERT.  ART. 


THYROID  BODY 


Fig.  49. — Diagrammatic   section  to  show  the  relations  of 
the  thyroid  body. 

thyroid  when  enlarged  may  distort  and  narrow 
the  trachea,  and  this  is  all  the  more  likely  to  be 
the  case  when  the  enlargement  occurs  rapidly, 
since  the  body  is  held  down  by  the  sterno-hyoid, 
sterno-thyroid,  and  omo-hyoid  muscles.  The  pos- 
terior or  outer  surface  of  the  thyroid  body  being 
in  contact  with  the  sheath  of  the  great  vessels, 
it  follows  that  the  gland  when  enlarged  may 
readily  receive  pulsations  from  those  vessels  (Fig. 
49).  It  generally  touches  also  the  lower  part  of 
the  pharynx,  and  the  upper  part  of  the  gullet 
behindhand  enlargement  in  this  direction  may,  in 


198  THE    HEAD    AND    NECK  [CHAP. 

connexion  with  the  interference  with  the  move- 
ment of  the  larynx  in  deglutition,  serve  to  ex- 
plain the  difficulty  in  swallowing  often  noticed 
in  bronchocele. 

The  isthmus  of  the  thyroid  gland  is  developed 
from  a  diverticulum  which  is  protruded  from 
the  ventral  wall  of  the  pharynx  in  the -embryo 
between  the  mandibular  and  hyoid  parts  of  the 
tongue  (Fig.  51,  p.  210).  The  foramen  caecum  of 
the  tongue  represents  the  point  at  which  the  diver- 
ticulum grew  out  from  the  pharynx.  From  this 
foramen  a  duct  (the  thyro-glossal)  may  be  found 
to  lead  to  accessory  gland  masses  about  the  hyoid 
bone.  In  the  vicinity  <  of  this  bone  accessory 
glands  and  small  cysts  lined  with  epithelium  are 
not  infrequently  met  with.  These  glands,  to- 
gether with  the  so-called  pyramid  or  middle  lobe, 
are  the  remains  of  the  neck  of  the  primitive  diver- 
ticulum. Below  the  level  of  the  hyoid  bone  the 
median  bud  divides ;  hence  the  pyramidal  lobe 
represents  the  stalk  of  the  right  or  of  the  left 
division  and  is  never  in  the  median  line.  The 
pyramid,  which  is  nearly  always  connected  to  the 
hyoid  bone  by  the  levator  thyrpidese,  exists  in  79 
per  cent,  of  the  subjects  examined  (Streckeisen). 
The  lateral  lobes  are  developed  from  the  fourth 
visceral  clefts  (Fig.  51).  The  median  diverticulum 
occasionally  fails  to  join  one  of  the  lateral,  in 
which  case  the  isthmus  is  partially  absent.  Small 
accessory  thyroid  bodies  are  frequently  present. 

The  parathyroid  bodies  appear  to  play  an 
essential  part  in  the  function  of  the  thyroid. 
They  are  of  the  size  of  small  peas,  and  have  a 
structure  similar  to  that  of  the  medulla  of  the 
suprarenal  bodies,  the  cells  being  grouped  in 
reticulating  columns.  Two  are  usually  found  on 
each  side,  one  behind  the  lower  pole  of  the  lateral 
lobe,  the  other  behind  the  lobe  amongst  the  ter- 
minal branches  of  the  inferior  thyroid  artery. 
Parathyroid  bodies  become  less  numerous  as  age 
advances,  so  that  in  the  aged  none  may  be  found 
(Forsyth).  The  parathyroid  bodies  may  develop 


ix]  MYXCEDEMA  199 

vesicles  containing  colloid  material,  and  thus  be- 
come very  similar  to  small  accessory  thyroids. 

Atrophy  of  the  thyroid  gland,  or  its  destruc- 
tion by  disease,  is  apt  to  lead  to  a  general  con- 
dition of  the  body  known  as  myxcedema.  The 
condition  closely  resembles  cretinism,  especially  as 
met  with  in  goitrous  subjects.  Myxoedema  may 
follow  the  entire  excision  of  the  thyroid  by  opera- 
tion, and  has  been  produced  in  monkeys  by  ex- 
perimental removal  of  the  gland.  One  prominent 
feature  of  myxredema  is  the  swelling  of  the  sub- 
cutaneous tissues  from  an  accumulation  therein 
of  a  mucinoid  substance. 

Vaso-motor  nerves  reach  the  thyroid  through  the 
lower  part  of  the  cervical  sympathetic  chain,  and 
by  the  same  course  nerves  pass  upwards  to  the  eye 
(see  p.  64).  These  nerves  appear  to  be  connected 
centrally,  probably  in  the  medulla,  for  in  certain 
conditions  enlargement  of  the  thyroid  is  accom- 
panied by  protrusion  of  the  eye  (exophthalmic 
goitre).  The  lymphatics  of  the  thyroid  gland  are 
numerous,  and  pass  to  the  deep  cervical  and 
superior  mediastinal  lymph-glands.  Asher  and 
Flack  found  that  the  internal  secretion  of  the 
thyroid  body  could  be  increased  by  stimulation  of 
the  laryngeal  nerves. 

The  superior  thyroid  artery  reaches  the  gland 
at  the  apex  of  the  lateral  lobe;  the  inferior 
thyroid  artery  enters  the  lower  part  of  the  lobe 
at  its  posterior  aspect.  In  securing  this  vessel, 
and  in  liberating  the  lower  part  of  the  gland 
during  excision,  the  recurrent  laryngeal  nerve  is 
in  great  danger  of  being  damaged.  If  it  be  cut 
or  included  in  a  ligature,  all  the  muscles  of  the 
larynx  on  that  side  become  paralysed,  save  the 
crico-thyroid.  The  thyroidea  ima  artery,  an  extra 
vessel  to  the  thyroid  body,  which  usually  arises 
from  the  innominate  and  ascends  in  front  of 
the  trachea,  is  found  in  one  subject  out  of 
every  ten. 

The  gullet  commences  opposite  the  sixth 
cervical  vertebra,  and  pierces  the  diaphragm 


200  THE    HEAD    AND    NEGK  [CHAP. 

opposite  the  tenth  dorsal  vertebra.  The  point  is 
marked  on  the  back  by  the  overlapping  spine  of 
the  ninth  dorsal  vertebra.  By  placing  the  stetho- 
scope a  little  to  the  left  of  this  spine,  fluid  may 
be  heard  to  enter  the  stomach.  The  gullet  pre- 
sents three  curves  :  one  is  antero-posterior,  and 
corresponds  to  the  curve  of  the  spinal  column ;  the 
other  two  are  lateral.  Commencing  at  the  middle 
line,  it  deviates  slightly  to  the  left  as  far  as  the 
root  of  the  neck;  thence  to  the  fifth  dorsal 
vertebra  it  gradually  returns  to  the  middle  line, 
and  finally  it  turns  again  to  the  left,  at  the  same 
time  passing  forwards,  to  pierce  the  diaphragm. 
Notwithstanding  these  natural  curvatures,  a 
rigid  and  straight  gastroscope  can,  in  expert 
hands,  be  passed  from  mouth  to  stomach.  Its 
length  is  from  9  to  10  inches.  There  are  three 
narrow  parts  in  the  gullet — one  at  its  commence- 
ment, one  about  2|  inches  from  that  point,  and 
a  third  where  the  tube  passes  through  the  dia- 
phragm. The  narrowing  at  the  commencement 
and  termination  of  the  oesophagus  is  due  to  the 
fact  that  the  musculature  at  these  points  is 
sphincteric  in  nature,  and,  except  during  the  pas- 
sage of  food,  the  lumen  in  these  parts  is  closed. 
Under  certain  conditions  the  sphincter  at  the 
lower  end  of  the  oesophagus  passes  into  a  state 
of  spasm  leading  to  dilatation  of  the  oesophagus 
from  accumulation  of  food.  In  its  open  state 
the  diameter  at  each  of  these  points  is  a  little  over 
^  an  inch  (14  mm.)  ;  the  diameter  elsewhere  is  about 
f  of  an  inch  (17  mm.  to  21  mm.).  By  forcible 
distension  the  two  upper  narrow  parts  could  be 
distended  to  a  diameter  of  18  to  19  mm.,  the  lower 
part  to  25  mm.,  and  the  rest  of  the  gullet  to  a 
diameter  of  nearly  1|  inches  (35  mm.).  Foreign 
bodies  when  swallowed  are  most  apt  to  lodge 
above  one  of  the  sphincters  either  at  the  com- 
mencement of  the  gullet  or  where  it  passes 
through  the  diaphragm  to  join  the  stomach.  The 
same  parts  also  are  those  most  apt  to  show  the 
effects  of  corrosives  that  have  been  .swallowed.  A 


ixj  FOREIGN  BODIES  IN  THE  (ESOPHAGUS   201 

third  point  of  arrest  is  where  the  oesophagus 
passes  behind  the  left  bronchus. 

Among  the  relations  of  the  oesophagus,  the 
following  may  be  noted  as  receiving  illustration 
in  surgical  practice  :  The  gullet  is  in  nearly  all 
its  course  in  close  relation  with  the  front  of 
the  vertebral  column.  In  the  neck  the  trachea 
is  immediately  in  front  of  it.  In  the  thorax 
it  has  the  left  bronchus,  left  bronchial  glands, 
pericardium,  and  left  auricle  in  front  of  it,  while 
the  two  vagi  form  a  plexus  on  it.  The  left 
bronchial  glands,  when  enlarged,  may  press  on  the 
gullet,  adhere  to  it,  or  even  cause  localized  soften- 
ing and  diverticula  to  spring  from  it.  The 
thoracic  duct  passes  behind  to  reach  the  left  side 
of  the  gullet  in  the  upper  part  of  the  thorax, 
while  in  the  lower  part  the  aorta,  at  first  to  the 
left  of  the  oesophagus,  gradually  becomes  pos- 
terior to  it.  It  is,  moreover,  partly  in  contact 
with  both  pleurae,  but  more  especially  with  the 
membrane  of  the  right  side ;  and,  lastly,  the  recur- 
rent laryngeal  nerve  ascends  between  it  and  the 
trachea.  (See  Figs.  57  and  102,  pp.  241  and  455.) 

Foreign  bodies  impacted  in  the  gullet  are  very 
apt  to  lead  to  ulcerations  that  may  open  ad- 
jacent f  parts.  Thus,  in  the  Musee  Dupuytren  is 
a  specimen  showing  a  five-franc  piece  which  had 
stuck  in  the  gullet,  and  had  produced  an  ulcer 
that  had  opened  the  aorta.  In  another  instance 
a  "  smasher  "  swallowed  a  counterfeit  half-crown 

Eiece.  Eight  months  afterwards  he  died  of 
semorrhage.  The  coin  had  sloughed  into  his 
aorta.  In  another  case  (Lancet,  1871),  a  fish-bone, 
lodged  in  the  gullet  opposite  the  fourth  dorsal 
vertebra,  had  caused  two  perforating  ulcers;  one 
on  the  right  side  had  caused  plugging  of  the  vena 
azygos  major,  while  the  other  on  the  left  had  made 
a  hole  in  the  aorta.  Less  frequently,  impacted 
foreign  substances  have  found  their  way  into  the 
trachea  and  into  the  posterior  mediastinum.  Dr. 
Ogle  reports  a  case  (Path.  Soc.  Trans.  >  vol.  iv.) 
where  a  piece  of  bone  impacted  in  the  gullet 


202  THE    HEAD    AND    NEGK  [CHAP. 


induced  ulceration  of  an  inter  vertebral  disc 
subsequent  disease  of  the  spinal  cord.  Carcinoma 
of  the  gullet,  also,  when  it  spreads,  is  apt  to 
invade  adjacent  parts,  and  especially  to  open  into 
the  trachea  or  bronchi.  If  it  spreads  to  the 
pleura,  it  will  usually  involve  the  right  pleura, 
as  being  the  membrane  more  in  relation  with  the 
gullet.  Cancer  of  the  gullet  has  so  spread  as  to 
invade  the  thyroid  body,  the  pericardium,  and 
the  lung,  and  has  opened  up  the  first  intercostal 
artery  in  one  case  and  the  right  subclavian  in 
another. 

The  sensory  nerve  supply  of  the  oesophagus 
comes  mainly  from  the  fifth  dorsal  segment  of  the 
cord  (Head).  In  cases  of  cancer  or  burns  of  the 
gullet,  pain  is  referred  to  the  skin  of  this  seg- 
ment (see  Fig.  79,  p.  359). 

CEsophageal  malformations.  —  In  the  newly  born 
the  upper  part  of  the  cesophagus  may  end  blindly, 
while  the  lower  part  commences  by  an  opening 
in  or  near  the  bifurcation  of  the  trachea,  so 
that  milk  could  reach  the  stomach  only  by  first 

Eassing  into  the  larynx  and  trachea.  Death  soon 
allows  from  suffocation  or  septic  pneumonia. 
The  condition  is  the  result  of  a  maldevelopment 
of  the  septum  which  ultimately  separates  the 
trachea  and  oesophagus.  Hernial  diverticula  of 
the  mucous  membrane  occasionally  occur  at  the 
junction  of  the  oesophagus  and  pharynx,  immedi- 
ately above  the  upper  sphincter  of  the  oesophagus. 
They  are  named  pharyngeal  pouches,  and  pro- 
trude between  the  lower  border  of  the  inferior 
constrictor  and  the  sphincteric  fibres  which  sur- 
round the  pharyngeal  orifice  of  the  oesophagus. 
The  diverticula  therefore  arise  opposite  the  cri- 
cpid  cartilage.  Since  the  fundus  of  the  pouch 
lies  between  the  upper  end  of  the  oesophagus  and 
the  spine,  it  necessarily,  when  filled  with  food, 
compresses  the  commencement  of  the  oesophagus. 

The  operation  of  oesophagotomy  consists  in 
incising  the  gullet  for  the  purpose  of  removing 
an  impacted  foreign  body.  The  gullet  is  usually 


ix]  BRASDOR'S   OPERATION  203 

reached  from  the  left  side,  since  it  projects  more 
on  that  aspect.  The  incision  is  made  between  the 
sterno-mastoid  and  the  trachea,  in  the  same  direc- 
tion as  the  incision  for  ligaturing  the  common 
carotid.  The  cut  extends  from  the  top  of  the 
thyroid  cartilage  to  the  sterno-clavicular  joint. 
The  omo-hyoid  muscle  is  drawn  outwards,  or  cut. 
The  great  vessels,  larynx,  and  thyroid  gland  are 
drawn  aside,  and  care  must  be  taken  not  to  wound 
these  structures  nor  damage  the  thyroid  vessels, 
thoracic  duct,  or  the  recurrent  nerve.  The  gullet, 
when  exposed,  is  opened  by  a  vertical  incision. 

Great  cervical  vessels. — The  course,  rela- 
tions, and  abnormalities  of  the  great  cervical 
vessels,  with  the  operations  whereby  they  may 
be  ligatured,  and  the  details  pertaining  to  those 
procedures,  are  so  fully  given,  not  only  in  works 
on  operative  surgery,  but  also  in  the  chief  ana- 
tomical text-books,  that  nothing  need  be  said  upon 
the  matter  in  this  place.  The  main  relationships 
of  the  carotid  and  subclavian  arteries  are  shown 
in  Fig.  44,  p.  176.  In  Brasdor's  operation  a  main 
trunk  is  ligatured  on  the  distal  side  of  an 
aneurysm,  no  branches  intervening  between  the 
sac  and  the  ligature.  The  cure  by  this  measure 
depends  upon  the  fact  that  blood  does  not  con- 
tinue to  go  to  parts  when  once  the  need  for  blood 
in  them  is  diminished.  Thus,  after  amputation 
at  the  hip-joint,  the  femoral  artery,  having  no 
need  to  carry  to  the  stump  the  amount  of  blood 
it  brought  to  the  limb,  often  shrinks  to  a  vessel 
no  larger  than  the  radial.  When  an  aneurysm  low 
down  in  the  carotid  artery  is  treated  by  ligature 
of  the  vessel  near  its  bifurcation  by  Brasdor's 
method,  the  blood,  having  now,  as  it  were,  no 
object  in  entering  the  carotid  trunk,  sodn  ceases 
to  fill  the  vessel  entirely,  and  the  artery  (and  in 
successful  cases  the  aneurysm)  shrinks  in  con- 
sequence. 

The  cervical  connective  tissue  being  lax,  aneu- 
rysms  in  this  part  can  grow  and  spread  rapidly, 
and  usually  soon  produce  "  pressure  symptoms." 


204  THE    HEAD    AND    NECK  [CHAP. 

As  examples  of  these  may  be  .noted  oedema  and 
lividity  of  the  face  and  of  the  upper  limb  from 
pressure  upon  the  main  veins,  laryngeal  symptoms 
from  pressure  upon  the  recurrent  nerve  or  trachea, 
spasm  of  the  diaphragm  from  pressure  upon  the 
phrenic  nerve,  damage  to  the  sympathetic,  and 
giddiness  and  impaired  vision  from  anaemia  of 
the  brain. 

The  vertebral  artery  has  been  ligatured  with 
doubtful  benefit  in  cases  of  epilepsy.  It  is  sur- 
rounded by  yaso-motor  nerves  derived  from  the 
inferior  cervical  ganglion,  which  also  are  neces- 
sarily tied.  The  artery  is  reached  through  an 
incision  made  along  the  posterior  border  of  the 
sterno-mastoid  muscle  just  above  the  clavicle  (see 
Fig.  44,  p.  176).  The  " carotid  tubercle"  is  then 
sought  for,  and  vertically  below  it  lies  the  artery, 
in  the  gap  between  the  scalenus  anticus  and 
iongus  colli  muscles.  The  procedure  is  sur- 
rounded with  considerable  difficulties. 

Air  in  veins. — The  veins  of  the  neck  are  under 
the  influence  of  the  respiratory  movements.  The 
veins  do  not  collapse  owing^  to  attachments  to 
the  surrounding  fasciae.  During  inspiration  these 
vessels  become  more  or  less  emptied;  during  ex- 
piration they  become  enlarged  and  turgid.  With 
greatly  impeded  breathing  they  may  attain  for- 
midable size.  Since  ether  usually  causes  some 
respiratory  difficulty,  it  is  seldom  administered 
in  operations  on  the  neck.  The  only  other  veins 
that  are  under  the  influence  of  the  aspiratory 
power  of  the  thorax  are  the  axillary  vein  and 
its  larger  tributaries.  When  any  one  of  these 
vessels  is  wounded,  and  the  wound  is  for  the 
moment  dry,  air  may  very  readily  be  drawn  into 
it  during  the  inspirator^  act,  just  as  air  is  drawn 
into  the  trachea.  The  air  causes  embolism  of  the 
pulmonary  capillaries. 

Valves  in  the  veins  of  the  neck. — The  subclavinn 
veins  and  their  tributaries  are  liberally  pro- 
vided with  valves,  but  the  internal  jugular  has 
only  one  pair,  situated  at  its  termination  in 


ix]  CERVICAL   SYMPATHETIC    CORD          205 

the  innominate  vein.  There  are  no  valves  in  the 
innominate  veins  or  in  the  superior  vena  cava. 
When  the  venous  pressure  within  the  thorax  is 
greatly  raised,  as  in  lifting  heavy  weights,  only 
the  terminal  valves  of  the  internal  jugular  vein 
prevent  the  transmission  of  the  pressure  to  the 
brain.  In  accidents  which  cause  sudden  com- 
pression of  the  thorax,  the  head  and  neck  may 
remain  livid  for  days  following  the  accident.  The 
lividity  is  probably  due  to  the  jugular  valves 
yielding,  thus  subjecting  the  capillaries  of  the 
head  and  neck  to  a  higher  pressure  than  they  are 
able  to  withstand. 

Cervical  part  of  the  sympathetic  cord, 
— If,  in  the  course  of  an  operation  on  the  neck, 
the  sympathetic  cord,  which  unites  the  superior, 
middle,  and  inferior  cervical  ganglia,  should  be 
cut  or  included  in  a  ligature,  a  remarkable  series 
of  symptoms  results,  chiefly  noted  in  the  eye  and 
orbit  of  the  same  side.  It  will  be  remembered 
that  the  nerve-fibres  which  supply  the  dilator 
muscle  of  the  iris,  the  non-striated  tarsal  muscle 
of  the  upper  lid,  the  non-striated  muscle  of  the 
orbit,  the  sweat-glands  of  the  face,  and  give 
vaso-motor  branches  to  the  arteries  of  the  face, 
tongue,  and  neck,  issue  from  the  spinal  cord  by 
the  anterior  roots  of  the  first  and  second  dorsal 
nerves.  They  pass  to  the  cervical  cord  in  the 
white  rami  of  these  two  nerves,  ascending  in  the 
cord  which  lies  behind  the  carotid  sheath.  The 
case  of  a  woman  in  whom  the  sympathetic  cord 
had  been  cut  during  the  removal  of  tubercular 
glands  from  the  right  side  of  the  neck  is  re- 
corded by  Dr.  Purves  Stewart.  "The  right  eyelid 
drooped  a  little,  the  right  side  of  the  face 
flushed  less  than  the  left;  when  she  chewed,  a 
small  patch  of  excessive  perspiration  appeared 
below  the  right  eye.  The  right  pupil  was  smaller 
than  the  left,  from  paralysis  of  the  dilator 
pupillje.  Moreover,  the  affected  pupil  does  not 
dilate  when  shaded,  yet  it  contracts  briskly  to 
light  and  on  convergence.  .  .  .  The  cilio-spinal 


206  THE    HEAD    AND    NECK  [CHAP. 

reflex  is  abolished;  the  pupil  no  longer  dilates 
when  the  skin  on  the  right  side  of  the  neck  is 
pinched." 

The  lymphatic  glands  of  the  head  and 
iieck  are  numerous*  and  arranged  in  the  follow- 
ing sets  (Fig.  50)  :  — 

(1)  Submandibular  glands,  10  to  15  in  number, 
situated  at  the  lower  border  of  the  jaw  beneath 
the  cervical  fascia;  (2)  the  suprahyoid,  1  or  2 
in  number,  situated  between  the  chin  and  hyoid 
bone  near  the  middle  line;  (3)  parotid  or  pre- 
auricular  set,  situated  in  and  over  the  parotid 
gland;  (4)  postauricular  or  mastoid,  2  to  4  in 
number,  situated  over  the  mastoid  process;  (5) 
occipital,  3  to  5  in  number,  over  the  insertion 
of  the  complexus  muscle;  (6)  superficial  cervical 
glands,  often  absent,  situated  over  the  sterno- 
mastoid  along  the  external  jugular  vein;  (7) 
laryngeal,  1  to  3  in  number,  below  the  great 
horn  of  the  hyoid ;  (8)  the  upper  deep  cervical  set, 
10  to  20  in  number,  situated  over  the  upper  part 
of  the  internal  jugular  vein  and  bifurcation  of  the 
common  carotid  artery;  (9)  lower  deep  cervical 
set,  surrounding  the  terminal  parts  of  the  in- 
ternal jugular,  subclayian,  external  jugular,  and 
transverse  cervical  veins.  This  set  becomes  con- 
tinuous with  the  axillary  and  mediastinal  glands. 

These  glands  are  very  often  enlarged  and  in- 
flamed, and  it  is  in  this  part  of  the  lymphatic 
system  that  tubercular  enlargement  of  lymph- 
glands  is  most  commonly  met  with.  The  inflam- 
matory affections  in  glands  would  appear  to  be 
always  of  a  secondary  nature,  and  to  follow  dis- 
turbances in  those  parts  of  the  periphery  whence 
they  respectively  receive  their  lymph.  It  may  be 
convenient,  therefore,  to  group  the  relations  of 
certain  glands  to  certain  parts  of  the  periphery. 

Scalp. — Posterior  part  =  occipital  and  post- 
auricular  glands.  Frontal  and  parietal  portions 
=  preauricular  glands  (Fig.  50). 

Vessels  from  the  scalp  also  enter  the  super- 
ficial cervical  set  of  glands. 


LYMPHATIC    GLANDS 


207 


Fig.  50. — Showing  the  positions  of  the  lymphatic  glands 
of  the  head  and  neck.  The  outlines  of  the  sterno- 
mastoid  (S.M.),  trapezius  (TR.),  internal  jugular, 
subclavian,  and  right  innominate  veins  are  shown. 

1,  Submandibular  glands,  1'  area  drained ;  2,  suprahyoid  glands, 
2'  area  drained  ;  3,  preauricular  glands,  3'  area  drained  ;  4,  post- 
auricular  glands,  4'  area  drained  ;  5.  occipital  glands,  5'  area 
drained  ;  6,  in  front  of  external  jugular  vein,  marking  position 
of  the  superficial  cervical  glands  ;  7,  laryngeal  gland ;  8,  8,  8, 
upper  deep  cervical  glands  ;  9,  9,  9,  lower  deep  cervical  glands  : 
10,  gland  receiving  lymph  from  thyroid  ;  11,  superior  mediastinal 
glands  ;  12,  axillary  glands. 


208  THE    HEAD    AND    NEGK  [CHAP. 

Skin  of  face  and  neck  —  submandibular,  piv- 
auricular,  and  superficial  cervical  glands. 

External  ear  =  superficial  cervical  glands. 

Lower  lip  =  submandibular  and  suprahyoid 
glands. 

Buccal  cavity  =  submandibular  glands  and 
deep  cervical  glands  (upper  set). 

Gums  of  lower  jaw   -  submandibular  glands. 

Tongue. — Anterior  portion  =  suprahyoid  and 
submandibular  glands.  Posterior  portion  =  deep 
cervical  glands  (upper  set). 

Tonsils  and  palate  =  deep  cervical  glands 
(upper  set). 

Pharynx. — Upper  part  =  preauricular  and 
retropharyngeal  glands.  Lower  part  =  deep 
cervical  glands  (upper  set). 

Larynx,  orbit,  and  roof  of  mouth  =  deep  cer- 
vical glands  (upper  set). 

Nasal  fosscR  —  retropharyngeal  glands,  deep 
cervical  glands  (upper  set).  Some  lymphatics 
from  the  posterior  part  of  the  fossae  enter  the 
preauricular  glands.* 

In  the  removal  of  the  deep  cervical  glands 
a  number  of  structures  are  liable  to  be  wounded. 
The  glands  frequently  become  firmly  adherent  to 
the  internal  jugular  vein;  the  uppermost  glands 
surround  the  spinal  accessory  nerve ;  the  super- 
ficial cervical  nerves  pass  among  those  of  the 
lower  deep  cervical  set ;  the  thoracic  duct  has  been 
wounded  in  removing  glands  from  the  left  supra- 
clavicular  fossa. 

Thoracic  duct  in  the  neck. — A  point  taken 
on  the  upper  border  of  the  clavicle,  1  inch  from 
its  sternal  end,  will  mark  the  angle  between  the 
internal  jugular  and  subclavian  veins  at. or  near 
which  the  thoracic  duct  ends.  In  40  bodies  in- 
vestigated by  Messrs.  F.  G.  Parsons  and  P.  W.  G. 
Sargent  the  duct  was  found  to  end  in  the  ter- 
minal part  of  the  internal  jugular  vein  in  35 
instances;  in  nearly  half  of  these  cases  the  ter- 

*  From  "  Scrofula,  ami  its  Gland  Diseases,"  by  Sir  Frederick  Treves. 
1882. 


ix]  BRANCHIAL   FISTULA  209 

minal  part  of  the  duct  divided;  it  frequently 
has  two  orifices,  and  may  have  as  many  as  four. 
At  its  termination  the  duct  curves  outwards  over 
the  scalenus  anticus  and  phrenic  nerve  above  its 
point  of  entrance  where  it  is  usually  furnished 
with  valves.  Ligature  of  the  duct  is  followed 
by  no  untoward  symptoms,  as  a  rule,  a  result 
which  is  due  to  the  free  anastomosis  that  exists 
between  it  and  the  lymphatics  ^of  the  right  side 
of  the  thorax  and  to  communications  with  the 
azygos  veins  (Leaf).  As  the  duct  ascends  behind 
the  left  common  carotid  and  subclavian  arteries 
to  enter  the  neck,  it  lies  in  contact  with  the 
pleura  and  lung.  On  the  right  side  the  thoracic 
duct  is  represented  by  the  right  lymphatic  trunk. 
The  tributaries  of  these  two  main  lymphatic 
channels  are  in  free  communication  within  the 
thorax. 

Branchial  fistulas — Certain  congenital  fis- 
tulas are  sometimes  met  with  in  the  neck,  which 
are  due  to  partial  persistence  of  one  of  the 
branchial  clefts.  These  clefts  are  placed  in  the 
foetus  between  the  branchial  arches.  The  arches 
are  usually  described  as  five  in  number.  The  first 
lays  the  foundation  for  the  lower  jaw  and  malleus. 
From  the  second  are  developed  the  styloid  process, 
the  stylo-hyoid  ligament,  and  lesser  cornu  of  the 
hyoid  bone.  From  the  third  are  formed  the  body 
and  greater  cornu  of  the  hyoid  bone,  while  the 
fourth  and  fifth  take  part  in  the  formation  of 
the  cartilages  and  soft  parts  of  the  neck  below  the 
hyoid  bone.  The  first  cleft  is  between^  the  first 
and  second  arches.  "The  cervical  branchial  fistulse 
appear  as  very  fine  canals  opening  into  minute 
orifices  in  one  or  both  sides  of  the  fore  part  of 
the  neck,  and  leading  backwards  and  inwards  or 
backwards  and  upwards  towards  the  pharynx  or 
oesophagus"  (Paget).  Their  length  is  about  li  to 
2 1  inches,  and  their  diameter  varies  from  that 
of  a  bristle  to  that  of  an  ordinary  probe.  The 
orifice  of  a  cervical  fistula  is  usually  situated 
just  above  the  sterno-clavicular  joint  (Fig.  51), 


210 


THE    HEAD    AND    NECK 


[CHAP. 


and  represents  the  orifice  of  the  cervical  sinus, 
a  depression  or  pocket  formed  during  the 
development  of  the  neck  of  the  foetus,  and 
serving  as  a  common  orifice  for  the  branchial 
or  visceral  clefts  in  which  the  tonsil,  thymus, 


Fig.  51. — Showing  the  positions  and  connexions  of  various 
embryological  remnants  in  the  neck. 

A,  Tonsil ;   B,  remnant  of  tonsillar  sac  (from  second  cleft  recess) ; 

C,  carotid  body  between  external  and  internal  carotid  arteries  ; 

D,  stalk  of  thymus  (third  cleft) ;  E,  cervical  sinus  (united  with 
second  cleft  recess  on  left  side) ;  F,  cervical  thymus ;  o,  com- 
mon carotid ;   G',  median  part  of  thyroid  and   Etyro-ffloseal 
duct;  H,  infrahyoid  part  of  median  thyroid  ;  I,  stalk  of  lateral 
thyroid  from  fourth  cleft ;  K  K,  thymus  in  thorax- 


ixj  BRANCHIAL    FISTULA  211 

and  lateral  thyroids  are  developed.  The  fistula, 
as  it  ascends,  passes  towards  the  bifurcation  of 
the  common  carotid,  where  it  may  come  into 
communication  with  the  carotid  body  (derived 
from  the  third  cleft),  or  with  the  tonsillar  recess 
(from  the  second  cleft).  It  can  be  understood 
that  only  parts  of  these  saccular  structures  and 
outgrowths  may  persist,  such  remnants  forming 
the  bases  for  cervical  cysts.  Certain  dermoid  cysts 
of  the  neck,  and  also  certain  polycystic  congenital 
tumours,  occurring  as  one  form  of  "hydrocele 
of  the  neck/'  also  arise  from  these  branchial 
remnants.  At  the  orifice  of  the  fistulse,  or  at  the 
position  where  they  usually  occur,  tags  of  skin 
containing  cartilage  may  appear.  They  are  termed 
supernumerary  auricles,  because  they  occupy  the 
same  relationship  to  the  fistulse  that  the  external 
ear  does  to  the  first  visceral  cleft. 

The  ventricle  of  the  larynx,  as  is  normally  the 
case  in  many  apes,  may  become  prolonged  into  a 
sac  which  passes  through  the  thyro-hyoid  mem- 
brane, thus  forming  a  cervical  air-cyst  or  sac  in 
the  laryngeal  region  of  the  neck. 


PART  II.— THE    THORAX 

CHAPTER   X 
THE  CHEST  AND  ITS  VISCERA 

THE  THORACIC  WALLS 

THE  two  sides  of  the  chest  are  seldom  sym- 
metrical, the  circumference  of  the  right  side  being 
usually  the  greater,  a  fact  that  is  supposed  to 
be  explained  by  the  unequal  use  of  the  upper 
limbs.  In  Pott's  disease,  involving  the  dorsal 
region,  when  the  spine  is  much  bent  forwards 
the  thorax  becomes  greatly  deformed.  Its  antero- 
posterior  diameter  is  increased,  the  sternum 
protrudes,  and  may  even  be  bent  by  the  bending 
of  the  spine,  the  ribs  are  crushed  together,  and 
the  body  may  be  so  shortened  that  the  lower 
ribs  overlap  the  iliac  crest. 

In  pigeon=breast  deformity  the  sternum  and 
cartilages  are  rendered  protuberant,  so  that  the 
antero-posterior  measurement  of  the  chest  is  much 
increased,  while  a  deep  sulcus  exists  on  either 
side  along  the  line  of  junction  of  the  ribs  and 
their  cartilages.  It  is  by  the  sinking-in  of  the 
parietes  along  the  costo-chondral  junctions  that 
the  protuberance  is  produced.  In  children,  and 
especially  in  rickety  children,  the  thorax  is  very 
pliable  and  elastic,  and  if  a  constant  impediment 
exists  to  the  entrance  of  air,  as,  for  example, 
from  greatly  enlarged  tonsils,  the  thoracic  walls 
may  yield  in  time  to  the  suction  brought  to  bear 
212 


KYPHORTS  AND  SCOLIOSIS 


213 


upon  them  at  each  inspiration.  The  weakest  part 
of  the  thorax  is  along  the  costo-choiidral  line 
on  either  side,  and  it  is  here  that  the  parietes 
yield  most  conspicuously  in  such  cases. 

Deformities  of  the  chest  result  from  abnormal 
curvatures  of  the  dorsal  part  of  the  spinal 
column.  The  ribs  are  firmly  bound  to  the  verte- 
brae by  the  costo-vertebral  and  costo-transverse 
ligaments,  and  hence  alteration  in  the  position  of 
vertebrae  is  attended  by  changes  in  the  costal 
series.  Thus,  when  there  is  kyphosis  in  the  dorsal 
region  the  upper  part  of  the  spine  is  bent  for- 
wards and  down- 
wards, carrying 
with  it  the 
upper  ribs  and 
the  sternum.  The 
antero  -  posterior 
diameter  of  the 
thorax  is  thereby 
increased,  but 
its  vertical  and 

mea"  Fig.  52. -Showing  the  changes  in  the 
thorax  which  follow  scoliosis  of 
the  spine.  (After  Redard.} 


The  convexity  of  the  spinal  curvature  is 
towards  the  right :  on  that  side  the  ribs 
are  sharply  bent  at  their  angles.  On  the 
concave  (left)  side  the  ribs  have  an  open 
angle. 


transverse 
snrements 
decreased.  When 
lateral  curvature 
is  produced  in 
the  dorsal  re- 
gion, the  ribs,  on 
the  side  towards 
which  the  bend  occurs,  are  necessarily  compressed, 
while  on  the  opposite  side  they  are  separated. 
In  scoliosis  of  the  spine  not  only  is  a  lateral 
curvature  formed,  but  the  vertebrae  undergo  a 
rotation  at  the  same  time.  The  vertebral  bodies 
move  towards  the  convex  side  of  the  column, 
and  their  spinous  processes  towards  the  con- 
cavity of  the  curvature  (Fig.  52).  The  ribs  on 
the  concave  side  are  carried  forwards  on  the  trans- 
verse processes  and  their  angles  open^out,  the  side 
of  the  chest  becoming  flattened  behind.  On  the 
other  side  (convex)  the  angles  are  unduly  promi- 


214  THE    THORAX  [CHAP. 

nent,  for  the  ribs  are  carried  backwards  at  their 
vertebral  extremities  and  bent  inwards  in  front. 
The  transverse  diameter  of  the  chest  thus  becomes 
oblique  (Fig.  52).  On  the  concave  side  the  inter- 
costal spaces  are  diminished  in  size,  the  ribs  even 
coming  into  contact,  while  on  the  convex  side 
the  spaces  are  increased  in  size.  The  thoracic 
viscera  are  necessarily  distorted  in  shape  and 
altered  in  position. 

The  sternum.— The  upper  edge  of  the  sternum 
corresponds  to  the  disc  between  the  second  and 
third  dorsal  vertebrae,  and  the  xiphisternal  joint 
to  the  middle  of  the  tenth  dorsal.  In  the  foetus 
at  full  term  the  upper  edge  of  the  sternum  is 
opposite  the  middle  of  the  first  dorsal  vertebra 
(Symington).  A  transverse  ridge  or  angle  may  be 
felt  upon  its  anterior  surface  that  corresponds  to 
the  junction  of  the  manubrium  and  body,  and  is 
in  a  line  with  the  second  costal  cartilages.  The 
bone  is  rarely  fractured,  being  soft  and  spongy, 
and  supported  by  the  elastic  ribs  and  their  cartil- 
ages, as  by  a  series  of  springs.  In  the  old,  when 
the  cartilages  are  ossified  and  the  chest  is  more 
rigid,  the  tendency  to  fracture  is  increased.  The 
sternum  is  most  of  ten  found  fractured  in  connexion 
with  injuries  to  the  spine,  although  it  may  be 
broken  by  simple  direct  violence.  The  bone  may 
be  fractured  by  violent  bending  of  the  spine  back- 
wards, and  by  abrupt  bending  of  it  forwards.  In 
the  former  instance  the  lesion  is  probably  due  to 
muscular  violence — to  the  abdominal  muscles  and 
the  sterno-mastoid  pulling  one  against  the  other. 
In  the  latter  instance  the  lesion  is  commonly 
brought  about  by  the  violent  contact  of  the  chin 
with  the  bone.  Dislocation  may  occur  at  the 
sterno-manubrial  joint  (sternal  synchondrosis). 
The  manubrium  in  these  injuries  generally  re- 
mains in  situ,  while  the  body  with  the  ribs  is 
displaced  forwards  in  front  of  it.  A  consider- 
able degree  of  respiratory  movement  takes  place 
at  the  sternal  synchondrosis;  only  in  very  old 
people  does  it  become  obliterated  by  bony  union. 


X]  STERNUM   AND   RIBS  215 

It  possesses  a  distinct  synovial  cavity  sur- 
rounded by  strong  fibrous  and  fibro-cartilagin- 
ous  ligaments.  Malgaigne  cites  the  case  of  a 
youth  who,  from  constant  bending  at  his  work  as 
a  watchmaker,  caused  the  second  piece  of  the 
sternum  to  glide  backwards  behind  the  manu- 
brium. 

From  its  exposed  position  and  cancellpus  struc- 
ture, the  sternum  is  liable  to  many  affections,  such 
as  caries  and  gummatous  periostitis.  The  com- 
parative softness  of  the  bone  is  such  that  it 
has  been  penetrated  by  a  knife  in  homicidal 
wounds.  The  shape  and  position  of  the  bone  have 
also  been  altered  by  pressure,  as  seen  sometimes 
in  artisans  following  employments  requiring  in- 
struments, etc.,  to  be  pressed  against  the  chest. 

Certain  holes  may  appear  in  the  middle  of  the 
sternum,  and  through  them  mediastinal  abscesses 
may  escape,  and  surface  abscesses  pass  deeply  into 
the  thorax.  These  holes  result  from  imperfect 
union  of  the  right  and  left  sternal  bars,  out  of 
which  the  sternum  is  formed.  In  the  case  reported 
by  E.  Groux,  the  bone  was  separated  vertically 
into  two  parts.  The  gap  could  be  opened  by 
muscular  effort  and  the  heart  exposed,  covered 
only  by  the  soft  parts.  The  sternum  has  been 
trephined  for  mediastinal  abscess,  and  for  para- 
centesis  in  pericardial  effusion,  and  it  has  been 
proposed  also  to  ligature  the  innominate  artery 
through  a,  trephine  hole  in  the  upper  part  of 
the  bone.  The  upper  part  has  been  divided 
vertically,  each  half  being  turned  forwards  and 
outwards  with  the  corresponding  ribs  in  order 
to  gain  access  to  the  structures  in  the  superior 
mediastinum. 

The  ribs  are  placed  so  obliquely  that  the  an- 
terior end  of  one  rib  is  on  a  level  with  the  pos- 
terior end  of  a  rib  some  way  below  it  in  numerical 
order.  Thus  the  second  rib  in  front  corresponds 
to  the  fifth  rib  behind,  and  the  insertion  of  the 
seventh  to  the  tenth.  If  a  horizontal  line  be 
drawn  round  the  body  at  the  level  of  the  inferior 


216  THE    THORAX  [CHAP. 

angle  of  the  scapula,  while  the  arms  are  at  the 
side,  the  line  would  cut  the  sternum  in  front  at 
the  attachment  of  the  sixth  cartilage,  would  cut 
the  fifth  rib  at  the  nipple  line,  and  the  ninth  rib 
at  the  vertebral  column.  The  second  rib  is  indi- 
cated by  the  transverse  ridge  on  the  sternum 
already  alluded  to  (angulus  Ludovici).  The  lower 
border  of  the  pectoralis  major  leads  to  the  fifth 
rib,  and  the  first  visible  serration  of  the  serratus 
magnus  corresponds  to  the  sixth.  The  longest  rib 
is  the  seventh,  the  shortest  the  first.  The  most 
oblique  rib  is  the  ninth.  As  the  arm  hangs  by 
the  side  the  lower  angle  of  the  scapula  covers 
the  seventh  rib. 

The  ribs  are  elastic  and  much  curved,  and, 
being  attached  by  many  ligaments  behind  to  the 
column,  and  in  front  to  the  yielding  cartilages, 
resist  with  the  qualities  possessed  by  a  spring  such 
injuries  as  tend  to  produce  fracture.  A  rib  may 
be  fractured  by  indirect  violence,  as  by  a  wheel 
passing  over  the  body  when  lying  prostrate  on  the 
back.  In  such  a  case  the  force  tends  to  approxi- 
mate the  two  ends  of  the  bone,  and  to  increase  its 
curve.  When  it  breaks,  therefore,  it  breaks  at 
the  summit  of  its  principal  curve,  i.e.  about  the 
centre  of  the  bone.  The  fragments  fracture  out- 
wards, and  the  pleura  stands  no  risk  of  being 
penetrated.  ^  When  the  rib  is  broken  by  direct 
violence,  lesion  occurs  at  the  spot  encountered  by 
the  force,  the  bone  fractures  inwards,  the  curve 
of  the  rib  tends  to  be  diminished  rather  than 
increased,  and  there  is  much  risk  of  the  fragments 
lacerating  the  pleura. 

The  ribs  most  often  broken  are  the  sixth,  seventh, 
and  eighth,  these  being,  under  ordinary  circum- 
stances, the  most  exposed.  The  rib  least  frequently 
fractured  is  the  first,  which  lies  under  cover  of  the 
clavicle.  In  elderly  people  dying  from  phthisis  the 
cartilage  of  the  first  rib  is  often  found  to  be  cal- 
cified and  occasionally  to  be  fractured.  Indeed, 
in  the  majority  of  people  over  45  the  cartilage 
of  the  first  rib  is  calcified  and  ossified  to  a 


x]          BIBS   AND   INTERCOSTAL  SPACES         217 

greater  or  less  degree,  and  there  is  no  doubt  that 
the  elasticity  and  mobility  of  such  ribs  are 
impaired.  In  cases  of  emphysema,  it  has  been 
proposed  to  divide  or  even  excise  the  cartilages 
of  the  upper  ribs  in  order  to  increase  the  re- 
spiratory capacity  and  mobility  of  the  thorax. 
Fractures  are  more  common  in  the  elderly  than  in 
children,  owing  to  the  ossification  of  the  cartilages 
that  takes  place  in  advancing  life.  When  a  rib 
is  fractured,  no  shortening  occurs,  the  bone  being 
fixed  both  in  front  and  behind,  while  vertical 
displacement  is  prevented  by  the  attachments  of 
the  intercostal  muscles.  Thus  no  obvious  de- 
formity is  produced  unless  a  number  of  consecu- 
tive ribs  are  the  subjects  of  fracture.  These 
bones  have  been  broken  by  muscular  violence, 
as  during  coughing,  and  in  violent  expulsive 
efforts  such  as  are  incident  to  labour.  In  such 
instances  the  ribs  are  probably  weakened  by 
atrophy  or  disease. 

In  rickets  changes  take  place  at  the  point  of 
junction  of  the  ribs  and  cartilages  which  lead 
to  bony  elevations,  producing,  when  the  ribs  on 
both  sides  are  affected,  the  condition  known  as  the 
"rickety  rosary."  The  costo-chondral  junctions 
at  which  these  enlargements  occur  correspond  to 
the  epiphyseal  lines  of  long  bones — lines  at  which 
growth  in  length  takes  place. 

The  intercostal  spaces  are  wider  in  front 
than  behind,  and  between  the  upper  than  the 
lower  ribs.  The  widest  of  the  spaces  is  the  third, 
then  the^  second,  then  the  first.  The  seventh, 
eighth,  ninth,  and  tenth  interspaces  are  very  nar- 
row in  front  of  the  angles  of  the  ribs.  The  first 
five  spaces  are  wide  enough  to  admit  the  whole 
breadth  of  the  index  finger.  The  spaces  are 
widened  in  inspiration,  narrowed  in  expiration, 
and  can  be  increased  in  width  by  bending  the  body 
over  to  the  opposite  side. 

Pa.racentesis  is  usually  performed  in  the  sixth 
or  seventh  space,  at  a  point  midway  between 
the  sternum  and  the  spine,  or  midway  between  the 


218  THE    THORAX  [CHAP. 

anterior  and  posterior  axillary  lines.  The  seventh 
space  can  be  readily  identified  by  its  relation- 
ship to  the  angle  of  the  scapula;  when  the  arm  is 
by  the  side  of  the  body  this  space  is  slightly  over- 
lapped by  the  angle.  If  a  lower  space  be  selected 
there  is  danger  of  wounding  the  diaphragm, 
especially  upon  the  right  side.  If  the  eighth  or 
ninth  space  be  selected  the  incision  is  made  just 
externally  to  the  line  of  tHe  angle  of  the  scapula. 
The  trocar  should  be  entered  during  inspiration, 
the  space  being  widened  thereby,  and  should  be 
kept  as  near  as  possible  to  the  lower  border  of  the 
space,  so  as  to  avoid  the  intercostal  vessels.  Tap- 
ping of  the  chest  through  any  space  posterior  to 
the  angles  of  the  ribs  is  not  practicable,  owing 
to  the  thick  covering  of  muscles  upon  the  thoracic 
wall  in  this  place,  and  the  fact  that  the  inter- 
costal artery,  having  a  more  horizontal  course 
than  the  corresponding  ribs,  crosses  the  middle 
of  this  part  of  the  space  obliquely.  Beyond  the 
angle  the  intercostal  vessels  lie  in  a  groove  on 
the  inferior  border  of  the  rib  forming  the  upper 
boundary  of  the  space.  The  vein  lies  immediately 
above  the  artery,  and  the  nerve  immediately  below 
it.  In  the  upper  four  or  five  spaces,  however,  the 
nerve  is  at  first  higher  than  the  artery.  Paracen- 
tesis  of  the  thorax  is  occasionally  followed  by  syn- 
cope or  even  death.  It  is  difficult  t9  account  for 
such  a  result;  it  may  be  a  reflex  inhibition  of  the 
heart  set  up  during  perforation  of  the  parietal 
pleura,  which  is  richly  supplied  by  the  intercostal 
nerves,  or  by  injury  to  the  lung,  which  is  supplied 
by  the  vagus. 

Pus  may  readily  be  conducted  along  the  loose 
tissue  between  the  two  layers  of  intercostal  mus- 
cles. Thus,  in  suppuration  following  upon  disease 
of  the  vertebrae,  or  of  the  posterior  parts  of  the 
ribs,  the  pus  may  be  conducted  along  the  inter- 
costal spaces  to  the  sternum,  and  may  thus  pre- 
sent at  a  considerable  distance  from  the  real  seat 
of  the  disease. 

Removal  of  ribs. — In   order   to    obtain    a   free 


xj  THE   FEMALE   BREAST  219 

opening  into  the  pleural  cavity  a  portion  of  one 
or  even  of  two  ribs  may  be  excised. 

In  some  cases  of  long-standing  empyema  with  an 
open  sinus,  all  that  part  of  the  bony  wall  of  the 
thorax  which  corresponds  to  the  outer  boundary 
of  the  suppurating  cavity  is  removed  in  order  that 
the  cavity  may  collapse  and  be  in  a  position  to 
close.  This  latter  measure  is  known  as  Estlander's 
operation,  or  thoracoplasty.  In  some  instances 
portions  of  as  many  as  nine  ribs  have  been  ex- 
cised, and  the  total  length  of  bone  removed  has 
reached  50  to  60  inches. 

In  removing  a  rib  the  bone  is  entirely  bared 
of  periosteum  with  the  rugine,  and  the  excision 
is  extraperiosteal.  In  this  way  the  intercostal 
vessels  are  not  exposed,  and,  if  divided  subse- 
quently, can  be  readily  secured  when  the  ribs 
are  out  of  the  way. 

The  internal  mammary  artery  runs  paral- 
lel to  the  border  of  the  sternum,  and  about  ^  an 
inch  from  it.  It  may  give  rise  to  rapidly  fatal 
haemorrhage  if  wounded.  The  vessel  may  readily 
be  secured  in  the  first  three  intercostal  spaces,  and 
with  some  difficulty  in  the  fourth  or  fifth  space. 
It  is  most  easily  reached  through  the  second  space, 
and  cannot  be  secured  through  any  space  below 
the  fifth. 

The  female  breast  extends  from  the  second 
rib  above  to  the  sixth  below,  and  from  the  side 
of  the  sternum  to  the  midaxillary  line  (Stiles). 
In  cases  of  retained  lactation  the  twelve  to  fifteen 
irregular  lobes  which  make  up  the  body  of  the 
gland  can  be  felt  radiating  outwards  from  the 
nipple.  The  lactiferous  ducts,  which  correspond 
in  number  to  the  lobes,  open  at  the  apex  of  the 
nipple,  within  which  each  shows  a  dilatation  or 
ampulla.  Branching  processes  of  adjoining  lobes 
unite  and  enclose  spaces  within  the  body  of  the 
gland,  containing  connective  tissue  and  masses  of 
fat.  After  the  menopause,  when  the  glandular 
tissue  is  absorbed  in  great  part,  and  during  the 
resting  condition,  fat  forms  the  greater  part  of 


220  THE    THORAX  [CHAP. 

the  female  breast.  Besides  the  main  body  of  the 
gland,  Stiles  has  drawn  attention  to  numerous 
peripheral  processes  which  lie  in  the  surrounding 
connective  tissue. 

Although  the  principal  part  of  the  breast  rests  on 
the  pectoralis  major,  quite  one-third  of  the  gland 
crosses  the  outer  border  and  rests  on  the  serratus 
magnus  within  the  axilla  (Fig.  53).  It  also  covers 
the  origins  of  the  obliquus  abdominis  externus  and 
rectus  abdominis.  In  excision  or  inflammation 
of  the  breast  it  is  important  to  bind  the  arm  by 
the  side  to  keep  the  parts  from  being  disturbed 
by  the  pectoralis  major.  Peripheral  processes  of 
the  gland  and  many  of  its  deep  lymphatics  enter 
the  pectoral  sheath,  hence  the  removal  of  this 
structure  with  part,  or  even  all,  of  the  pectoral 
musculature  if  complete  extirpation  of  cancer  is 
to  be  assured.  The  loose  retromammary  tissue 
which  binds  the  mamma  loosely  to  the  pectoral 
sheath  may  be  the  seat  of  abscess,  or  sometimes  of 
a  bursal  cyst. 

The  nipple,  in  the  male  and  in  the  virgin 
female,  is  situated  on  the  fourth  intercostal  space, 
about  |  of  an  inch  from  the  junction  of  the  ribs 
with  their  cartilages ;  after  lactation  the  breast 
becomes  pendent,  and  the  nipple  no  longer  serves 
as  a  guide  to  the  intercostal  spaces.  The  nipple 
contains  erectile  and  muscular  tissue,  and  is 
richly  supplied  by  cutaneous  branches  of  the  third 
and  fourth  spinal  nerves.  It  is  also  furnished 
with  a  rich  network  of  lymphatic  vessels,  which, 
when  the  breast  is  the  site  of  cancer,  may  become 
invaded  and  blocked  with  cancerous  epithelium, 
giving  rise  to  the  condition  known  as  Paget's 
disease  of  the  nipple  (Handley).  The  skin  is 
pigmented,  thin,  and  sensitive,  and  often  the  seat 
of  painful  fissures  and  excoriations.  In  painful 
diseases  of  the  breast,  tender  areas  occur  over 
the  fourth  and  fifth  spinal  segments  (Fig.  79, 
p.  359)  (Head). 

The  breast  is  developed  by  a  solid  invagination 
of  epiblast  at  the  point  afterwards  marked  by 


xj  LYMPHATICS   OF  THE   BREAST  221 

the  nipple.  About  the  sixth  month  of  foetal  lil'r 
the  primitive  mammary  bud  branches  out  in  all 
directions  within  the  subcutaneous  tissue.  Thus 
it  comes  about  that  the  subcutaneous  fascia  is  con- 
densed around  the  gland,  forming  its  capsule.  The 
retromammary  part  of  the  capsule  is  connected  at 
the  interlobular  spaces  with  the  superficial  layer, 
which  in  turn  is  fixed  to  the  skin  by  subcutaneous 
bands,  or  skin  ligaments. 

It  is  through  lymph  channels  that  cancer 
spreads,  and  those  of  the  breast,  which  is  one  of 
the  commonest  sites  of  cancer,  are  of  especial  im- 
portance if  complete  eradication  of  the  disease  is 
to  be  obtained.  The  lymph-vessels  are  arranged 
in  the  following  sets:  (1)  Perilobular,  round  the 
acini  and  lobules ;  (2)  periductal,  round  the  lac- 
tiferous ducts ;  (3)  interlobar,  situated  in  the 
interlobar  septa  and  joining  (4)  the  retromam- 
mary network  with  (5)  the  superficial  mammary 
in  the  anterior  part  of  the  capsule.  If  the  inter- 
lobar septa  are  invaded  by  cancer  they  contract, 
and  through  their  cutaneous  attachments  cause 
depressions  in  the  skin;  if  the  process  invades  the 
periductal  vessels,  the  nipple  is  retracted.  The 
mammary  lymphatic  system  is  connected  with  the 
subcutaneous  network  of  vessels,  to  which  cancer 
may  spread,  producing  that  variety  of  the  disease 
known  as  cancer  en  cuirasse.  Through  communi- 
cations with  the  lymph  channels  of  the  pectoral 
fascia  and  muscle,  cancer  of  the  breast  may  spread 
to  these  structures.  The  gland  then  becomes 
firmly  fixed  to  the  deeply  seated  structures.  The 
majority  of  the  lymph- vessels  pass  from  the  breast 
fcp  the  pectoral  alands,  six  to  eight  in  number, 
situated  along  the  anterior  border  of  the  axilla, 
and  to  the  central  axillary  set,  twelve  to  fifteen  in 
number,  situated  beneath  the  axillary  tuft  of  hair 
and  on  the  inner  side  of  the  axillary  vein  (Fig.  53). 
From  these  two  sets  the  lymph-vessels  pass  to  the 
deep  axillary  glands  lying  along  the  front  and 
inner  side  of  the  axillary  vessels.  The  deep  axil- 
lary glands  become  continuous  with  the  lower  deep 


222 


THE    THORAX 


[CHAP. 


cervical  glands.  It  is  mainly  along  this  path  that 
cancer  tends  to  spread,  but  vessels  leave  the  inner 
segment  of  the  breast  and  pass  to  the  anterior 
intercostal  glands  situated  in  the  upper  four 
intercostal  spaces  and  lying  on  each  side  of  the 
internal  mammary  vessels,  while  occasionally  a 


AXILLARY    SET 


AXILLARY   S£T 

\  OE.EP    CERVICAL    SET 


CENTRAL    SET 


AX'LLARY    LOBE 


PECTORAL   S£T 


Fig.  53. — Lymphatic  vessels  and  glands  of  the  breast 
and  axilla.     (Modified  from  Poirifir.) 

few  vessels  pass  to  the  cephalic  gland  situated 
in  the  hiatus  between  the  deltoid  and  pectoralis 
major  muscles.  Handley  found  a  marked  ten- 
dency for  breast  cancer  to  spread  downwards  in 
the  lymphatics,  passing  to  the  epigastric  triangle. 
There  the  vessels  perforate  the  belly  wall  to  join 
lymphatics  both  above  and  below  the  diaphragm  ;  it 


x]       ARTERIES   SUPPLYING   THE   MAMMA      223 

is  probably  owing  to  this  communication  that  the 
liver  is  so  often  the  seat  of  secondary  deposit  in 
cases  of  cancer  of  the  breast.  When  the  normal 
channels  become  clogged  with  cancerous  invasion, 
the  lymph  passes  by  circuitous  paths.  The  sub- 
scapular  glands,  surrounding  the  subscapular 
vessels  on  the  posterior  wall  of  the  axilla,  may 
become  infiltrated;  through  the  lymphatics  of  the 
arm,  which  end  in  the  central  axillary  glands, 
the  structures  round  the  shoulder  may  become  the 
seats  of  secondary  deposit;  and  through  the  com- 
munication between  the  lymph  system  of  one 
breast  with  that  of  the  other,  across  the  sternum, 
a  secondary  deposit  may  even  occur  in  the  oppo- 
site breast  (Stiles). 

The  intercosto-humeral  nerve  pierces  the  cen- 
tral set  of  axillary  glands.  It  becomes  compressed 
when  these  glands  are  invaded  by  cancer,  and 
pain  is  referred  to  the  termination*  of  the  nerve 
over  the  posterior  aspect  of  the  arm  above  the 
elbow.  Various  parts  of  the  brachial  plexus  may 
also  become  involved,  or  the  axillary  vein  or 
lymphatics  occluded,  the  arm  being  swollen  and 
cedematous  in  consequence. 

The  following  groups  of  arteries  supply  the 
gland  and  are  cut  in  excision  of  the  organ  :  (1) 
the  lateral  (long)  thoracic,  alar  thoracic,  thoracic 
branches  of  the  acromio-thoracic  axis ;  (2)  anterior 
perforating  branches  from  the  internal  mammary 
at  the  second,  third,  and  fourth  intercostal  spaces ; 
(3)  lateral  branches  from  the  second,  third,  and 
fourth  intercostal  arteries. 

Supernumerary  nipples  and  breasts  may  occur. 
They  are  commonly  found  in  a  line  between  the 
axilla  and  the  groin.  In  the  embryonic  stage  of 
all  mammals  an  epiblastic  mammary  ridge  is 
found  in  this  position.  In  man  it  disappears 
except  at  one  point,  but  occasionally  some  isolated 
part  may  persist  and  proceed  to  form  a  breast 
Embryology  fails  to  explain  the  occurrence  of 
breasts  on  the  buttock  or  back,  where  they  are 
occasionally  found. 


224 


THE    THORAX 


[CHAP. 


THE  THOKACIC  VISCERA 

Tlie  lung.— The  apex  of  the  lung  rises  in  the 
neck  from  1  to  2  inches  above  the  inner  half  of 
the  clavicle.  Its  highest  point  in  the  majority 
of  adults  lies  li  inches  above  the  sternal  end  of 
the  clavicle,  in  the  interval  between  the  sternal 
and  clavicular  heads  of  the  sterno-mastoid  muscle 


Fig.   54. — Showing  surface  markings  for  the  lungs 
and  pleura. 

(Fig.  54).  The  anterior  edges  of  the  two  lungs 
pass  behind  the  sterno-clavicular  articulations, 
and  meet  in  the  middle  line  at  the  sternal 
synchondrosis.  The  edge  of  the  right  lung  then 
continues  vertically  downwards  behind  the  middle 
line  of  the  sternum  to  the  sixth  chondro-sternal 
articulation,  where  it  slopes  off  along  the  lino 
of  the  sixth  cartilage.  The  edge  of  the  left 
lung  keeps  close  to  that  of  the  right  as  far  as 


xj  THE   LUNGS  225 

the  fourth  chondro-sternal  articulation,  where  it 
turns  off  to  the  left,  following  a  line  drawn 
from  the  fourth  cartilage  to  near  the  apex  of  the 
heart  (Fig.  54).  Occasionally  it  does  not  diverge, 
but  completely  covers  the  pericardium  up  to  the 
edge  of  the  sternum.  In  the  child,  owing  to  the 
thymus,  the  lungs  are  more  separated  in  front. 
The  right  reaches  the  middle  line,  but  the  left  only 
reaches  the  left  edge  of  the  sternum  (Symington). 
The  easiest  and  also  the  most  accurate  method  of 
indicating  the  lower  border  of  the  lung  is  the  fol- 
lowing (Fig.  54)  :  A  line  is  drawn  along  the  sixth 
costal  cartilage  from  its  sternal  end  to  its  heel; 
from  the  heel  the  line  is  carried  horizontally 
round  the  body;  it  will  be  found  to  cross  the 
median  line  behind,  at,  or  near  the  eleventh  dorsal 
spine  (the  anticlinal  spine).  The  corresponding 
border  of  the  pleura  is  not  parallel  to  the  lower 
border  of  the  lung ;  it  is  indicated  by  a  line  drawn 
along  the  seventh  costal  cartilage  from  its  sternal 
end  to  its  heel ;  from  there  the  line  is  continued 
to  a  point  2  inches  above  the  lowest  part  of  the 
subcostal  margin  and  then  prolonged  horizontally 
to  the  median  line  behind  where  it  crosses  at  or 
near  the  twelfth  dorsal  spine.  Between  the  pul- 
monary line  above  and  the  pleural  line  below,  the 
diaphragm  is  in  contact  with  the  chest  wall,  separ- 
ated only  by  the  costo-phrenic  reflection  of  the 
pleura.  On  the  left  side  these  lines  commence  at 
a  variable  distance  from  the  sternum — 1  inch 
should  be  allowed  for  the  pleura ;  2|  inches  for  the 
lung  (Fig.  54).  The  pleura  is  in  relation  with 
the  twelfth  rib,  but  occasionally  it  descends  \  an 
inch  or  more  below  the  neck  of  this  rib,  and  may 
be  wounded  in  operations  on  the  kidney  (Fig.  102, 
p.  453).  It  extends  lower  down  in  the  child  than 
in  the  adult.  The  left  lung  descends  to  a  slightly 
lower  level  than  the  right. 

In  penetrating:  wounds  involving  the  pleura, 
air  may  enter  the  pleural  cavity,  producing 
pneumothorax,  and  this  air  may  be  subsequently 
pressed  by  the  respiratory  movements  into  the 


226  THE    THORAX  [CHAP. 

subcutaneous   tissues   through   the   wound   in   the 

?arietal  pleura,  and  lead  to  surgical  emphysema, 
n  injuries  of  the  lung  without  external  wound, 
as  when  that  organ  is  torn  by  a  fractured  rib, 
the  air  escapes  from  the  lung  into  the  pleura, 
and  may  thence  pass  into  the  subcutaneous  tissues 
through  the  pleural  wound,  thus  producing  both 
pneumothorax  and  emphysema. 

Modern  bullets  of  high  velocity  penetrate  the 
lung  without  giving  rise  to  a  great  degree  of 
damage  to  the  pulmonary  tissues,  or  causing  much 
haemorrhage  into  the  pleural  space  (hsemothorax). 
This  result  is  due  to  the  fact  that  the  lungs 
contain  air  which  is  compressible,  and  lie  inside 
an  elastic-walled  cavity.  The  same  bullet,  entering 
the  medullary  cavity  of  a  bone,  or  the  skull, 
causes  an  explosive  effect  because  the  marrow  or 
brain  is  incompressible  and  locked  up  within  a 
closed  chamber. 

It  is  well  to  note  that  emphysema  may  occur 
about  certain  non-penetrating  wounds  of  the  thorax 
when  they  are  of  a  valvular  nature.  In  such 
cases  the  air  is  drawn  into  the  subcutaneous 
tissues  during  one  respiratory  movement,  and  is 
forced  by  another  into  the  cellular  tissue,  the  valv- 
ular nature  of  the  wound  preventing  its  escape 
externally.  Rupture  of  an  air-vesicle  of  the  lung 
during  violent  muscular  effort,  as  in  childbirth, 
may  give  rise  to  extensive  emphysema  of  the  thorax 
and  neck.  When  the  pleural  "cavity"  is  opened, 
the  lungs,  owing  to  the  amount  of  elastic  tissue 
they  contain,  undergo  some  degree  of  collapse,  but 
there  is  much  misconception  regarding  the  extent 
to  which  this  takes  place.  Half  the  air  in  the 
lung,  in  some  cases  even  two-thirds,  is  residual 
and  cannot  be  expelled  by  the  passive  collapse  of 
the  lung;  when  the  diaphragm  is  pushed  up  and 
the  ribs  are  pulled  down  by  the  expiratory  efforts 
of  the  muscles  of  the  belly-wall  the  thoracic  space 
may  be  so  reduced  in  size  that  the  lung  still  more 
than  fills  it;  if  the  glottis  be  closed  a  hernia  of  the 
lung  will  occur  through  the  wound  in  the  chest 


xj          WOUNDS   OF  PLEURA  AND  LUNG        227 

wall.  If,  however,  there  is  a  valvular  orifice  into 
the  pleural  cavity,  so  that  air  can  be  sucked 
in  but  not  expelled  from  it,  every  respiratory 
effort  increases  the  amount  of  air  in  the  pleural 
space;  then  compression  of  the  lung  and  suffo- 
cation quickly  ensue.  Air  or  fluid  introduced 
within  the  healthy  pleural  cavity  is  rapidly 
absorbed.  Air  is  much  more  quickly  absorbed 
by  the  pleura  than  is  a  pleural  effusion  or  blood. 
Hence  the  practice  of  replacing  the  blood  or  fluid, 
as  it  is  being  withdrawn,  by  an  equal  volume 
of  purified  air.  As  the  air  is  absorbed  the 
lung  tends  to  expand  to  fill  the  vacuum  created. 
Macewen  is  of  opinion  that  collapse  of  the  lung 
is  prevented  by  the  capillary  attraction  which 
exists  between  the  visceral  and  parietal  layers 
of  the  pleura. 

In  wounds  of  the  lung  the  blood  may  escape 
in  three  directions  :  into  the  tissue  of  the  organ 
(pulmonary  apoplexy),  into  the  bronchi  (causing 
haemoptysis),  and  into  the  pleura,  (causing  hsemo- 
thorax).  In  some  instances  the  lung  has  been 
ruptured  without  wound  and  without  fracture  to 
the  ribs. 

Owing  to  the  fineness  of  its  capillaries,  and  to 
the  fact  that  all  venous  blood  returned  to  the  heart 
must  pass  through  the  lungs  before  it  can  reach 
other  parts  of  the  body,  it  follows  that  pysemic 
and  other  secondary  deposits  are  more  commonly 
met  with  in  the  lung  than  in  any  o.ther  of  the 
viscera. 

Lung  cavities  resulting  from  tuberculosis,  gan- 
grene, or  bronchiectasis  have  been  successfully 
incised  and  drained,  and  the  same  measure  has 
been  applied  to  hydatid  cvsts  of  the  lung.  Deep 
incisions  in  the  lung  are  followed  by  less  haemor- 
rhage than  might  be  expected  from  such  a  vas- 
cular organ.  In  tuberculosis  of  the  lungs  pleural 
adhesions  are  soon  formed,  and  the  lung  is  thus 
firmly  bound  to  the  chest-wall.  In  order  that 
the  part  of  the  lung  which  is  the  site  of  a  large 
cavity  may  be  allowed  to  collapse,  thus  obliterating 


228  THE    THORAX  [CHAP. 

the  cavity  and  permitting  it  to  heal,  the  prac- 
tice of  opening  the  thoracic  wall  and  breaking 
down  the  adhesions  has  been  recently  introduced. 
It  is  too  soon  to  form  an  estimate  of  the  results 
of  this  daring  measure. 

Nerve  supply  of  the  pleura. — In  acute  inflam- 
mation of  the  pleura,  pain  may  be  very  intense, 
and  the  respiratory  movements  on  the  side  affected 
may  be  greatly  diminished.  The  pain,  if  in  the 
lower  part  of  the  thorax,  may  be  referred  to  the 
abdomen.  The  explanation  of  these  facts  must 
be  sought  in  the  nerve  supply  of  the  pleura.  The 
costal  pleura  is  supplied  *by  the  adjacent  inter- 
costal nerves,  which  also  supply  the  corresponding 
intercostal  muscles.  The  muscles  are  inhibited 
when  the  underlying  parts  of  the  pleura  are  in- 
flamed. The  lower  six  dorsal  nerves  also  supply 
the  abdominal  wall ;  hence  pain  arising  in  the 
costal  pleura  may  be  referred  by  the  patient  to 
the  abdomen,  and  lead  to  a  suspicion  of  abdominal 
disease.  The  diaphragmatic  and  the  mediastinal 
pleura  are  supplied  by  the  phrenic  nerves,  and 
pain  arising  in  these  parts  may  be  referred  to 
the  neck  or  shoulder.  The  cervical  pleura  is  also 
supplied  by  the  phrenic  nerve  (H.  M.  Johnston). 

The  tracliesi  divides  opposite  the  junction  of 
the  sternal  synchondrosis  in  front,  and  the  fourth 
dorsal  vertebra  behind.  In  the  fork  of  the 
bronchi,  and  accompanying  the  bronchi  into  the 
roots  of  the  lungs,  are  chains  of  lymphatic 
glands.  These  become  enlarged  in  all  inflam- 
matory conditions  of  the  lungs,  giving  rise  to 
opacities  in  radiograms  of  the  thorax  and  to  a 
dullness  on  percussion  on  each  side  of  the  upper 
five  dorsal  vertebrae  (Clive  Riviere). 

The  presence  of  foreign  bodies  in  the  air- 
passages  has  already  been  considered  (p.  195) ;  but 
it  may  here  be  pointed  out  that  in  some  cases 
they  have  shown  a  remarkable  facility  for  escaping 
through  the  parietes.  Thus,  Sir  Rickman  Grodlce 
records  the  case  of  a  child,  from  an  abscess  in 
whose  back  there  escaped  a  head  of  rye-grass 


x]  THE  PERICARDIUM  22§ 

that  had  found  its  way  into  the  air-passages 
forty-three  days  previously. 

Foreign  bodies  in  the  trachea  and  bronchi  can 
now  be  located  and  extracted  by  aid  of  the 
bronchoscope.  The  mucous  membrane  at  the  bi- 
furcation of  the  trachea  is  highly  sensitive,  and 
the  orifices  of  the  secondary  bronchial  tubes  can 
be  seen  to  contract  and  dilate  by  virtue  of  the 
circular  musculature  in  their  walls. 

The  root  of  the  lung  and  bronchi  can  be  ex- 
posed by  opening  the  dorsal  wall  of  the  thorax 
behind  the  vertebral  border  of  the  scapula.  Rus- 
sell and  Fox  record  the  case  of  a  boy  in  whom  a 
pin,  3  inches  long,  had  slipped  head  downwards 
within  the  trachea,  and  ultimately  lodged  in  the 
lower  division  of  the  left  bronchus.  They  resected 
part  of  the  eighth  rib  from  the  back,  pushed  the 
lung  forwards  to  expose  the  bronchus  at  the  root, 
and  removed  the  pin.  The  root  of  the  lung  re- 
quires to  be  steadied;  through  the  pericardium  it 
is  intimately  bound  to  the  diaphragm  and  follows 
the  movements  of  that  muscle.  In  the  case  men- 
tioned above,  the  boy  was  able  to  leave  the  hospital 
twelve  days  after  the  operation. 

The  heart  and  pericardium.—  The  position 
and  extent  of  the  pericardium  may  be  indicated 
thus  on  the  surface  of  the  thorax  (Fig.  55)  :  Three 
points  are  taken  :  (1)  the  apical,  over  the  apex 
beat,  in  the  fifth  left  intercostal  space,  3i  inches 
from  the  sternum;  (2)  the  sterno-manubrial,  mid- 
way between  the  insertions  of  the  second  costal 
cartilages;  (3)  the  inferior  caval,  1  inch  to  the  right 
of  the  sterno-ensiform  (sterno-xiphoid)  point  and 
directly  superficial  to  the  termination  of  the  in- 
ferior vena  cava.  When  these  three  points  are 
united  by  curved  lines,  as  in  Fig.  55,  the  area  over 
the  pericardium  and  its  contents  is  marked  out. 
The  lower  line  crosses  \  an  inch  or  more  below  the 
sterno-ensiform  point;  if  a  trocar  be  thrust  back- 
wards in  the  angle  between  the  ensiform  process 
and  seventh  left  costal  cartilage,  it  enters  the 
pericardium  just  above  the  diaphragm.  Through 


230 


THE    THORAX 


[CHAP. 


this  angle  the  pericardium  may  be  drained ;  by 
resecting  part  of  the  fifth  and  sixth  cartilages 
its  cavity  may  be  explored.  The  right  border  of 
the  pericardium  is  deeply  placed  and  covered  by 
the  right  lung  (Fig.  54) ;  in  health  it  should  not 
project  more  than  1  inch  beyond  the  right  sternal 
border. 

Besides  the  auricles  and  ventricles  the  follow- 


RIC.HT  IMT.  JUGULAR  VE 

RiCHT  5UBCLAV! 


l/t /ion. Vein 

ARCM  OP  AORTA 

Ry  ART. 


Fig.  55.— Relationship   of  the   pericardium   and  heart  to 
the  sternum  and  ribs. 

ing  parts  are  contained  in  the  pericardium  :  The 
terminations  of  the  inferior  and  superior  venae 
cavse ;  the  ascending  aorta  and  pulmonary  artery. 
The  position  of  these  parts,  and  of  the  arch  of  the 
aorta  and  its  branches,  is  shown  in  Fig.  55.  It 
will  be  observed  that  more  than  two-thirds  of  the 
anterior  surface  of  the  heart  is  made  up  of  right 
ventricle  and  auricle;  consequently  it  is  these 


x]  WOUNDS   OF  THE  HEART  231 

parts  which  are  usually  perforated  in  stabs  of  the 
heart. 

The  heart  may  be  exposed  for  operative  treat- 
ment by  removal  of  the  terminal  inch  or  more  of 
the  fourth  and  fifth  left  costal  cartilages.  The 
heart  may  be  freely  handled  and  sutured;  the 
surgeon's  task  is  rendered  difficult  by  its  rapid 
motions  and  the  respiratory  movements  of  the 
pericardium  and  diaphragm.  When  the  heart  is 
wounded,  blood  escapes  into  the  pericardium,  lead- 
ing to  compression  of  the  auricles  and  the  arrest  of 
the  inflow  of  blood.  Hydrops  of  the  pericardium 
may  cause  death  in  a  similar  manner.  Other 
things  being  equal,  a  wound  of  the  ventricle 
is  less  rapidly  fatal  than  is  a  wound  of  the 
auricle,  owing  to  the  thickness  of  the  ventricular 
wall,  and  to  its  capacity  for  contracting  and 
preventing  the  escape  of  blood.  Many  instances 
have  been  recorded  to  show  that  the  heart 
may  be  very  tolerant  of  foreign  bodies  in  its 
substance.  Thus  a  man  lived  for  twenty^  days 
with  a  skewer  traversing  the  heart  from  side  to 
side  (Ferrus).  In  another  case  a  lunatic  pushed 
an  iron  rod,  over  6  inches  in  length,  into  his 
chest,  until  it  disappeared  from  view,  although  it 
could  be  felt  beneath  the  skin  receiving  pulsation 
from  the  heart.  He  died  a  year  following,  and 
the  metal  was  found  to  have  pierced  not  only  the 
lungs  but  also  the  ventricular  cavities  (Tillaux). 
The  heart,  too,  is  tolerant  of  foreign  bodies  lying 
within  its  chambers.  During  the  Great  War  a 
considerable  number  of  soldiers  were  observed  to 
have  a  bullet  or  fragment  lying  free  within  the 
right  ventricle,  and  yet,  in  such  cases,  no  wound 
could  be  found  anywhere  in  the  wall  of  the  heart. 
The  bullet  in  such  cases  finds  its  way  into  one  of 
the  great  veins,  and  is  swept  with  the  venous  blood 
to  the  right  chambers.  In  no  case  had  the  foreign 
body  been  carried  into  the  pulmonary  artery. 
Wounds  of  the  heart  have  been  sutured,  the  in- 
sertion of  the  stitches  causing  only  momentary 
disturbance  of  its  action.  Travers  has  sutured 


232  THE    THORAX  [CHAP. 

a  wound  of  the  right  ventricle  into  which  he 
was  able  to  place  three  fingers  to  prevent  haemor- 
rhage. Apropos  of  chest  wounds,  Velpeau  cites 
the  case  of  a  man  in  whose  thorax  was  found 
a  part  of  a  foil  that  entirely  transfixed  the  chest 
from  ribs  to  spine,  and  that  had  been  introduced 
fifteen  years  before  death.  In  the  museum  of  the 
Royal  College  of  Surgeons  is  the  shaft  of  a  cart 
that  had  been  forced  through  the  ribs  on  the  left 
side,  had  passed  entirely  through  the  chest,  and 
had  come  out  through  the  ribs  on  the  right  side. 
The  patient  had  lived  ten  years. 

Paracentesis  of  the  pericardium — As  already 
mentioned,  the  pericardium  may  be  tapped  or 
drained  through  the  left  cqsto-ensiform  angle 
(Fig.  55).  The  extent  to  which  it  is  covered  by 
the  left  pleura  and  lung  is  extremely  variable, 
but  in  the  majority  of  cases  it  may  be  tapped  in 
the  left  fourth  and  fifth  spaces,  as  far  as  1  inch 
from  the  sternum,  without  injuring  the  pleura. 
The  internal  mammary  artery  descends  in  these 
spaces  ^  an  inch  from  the  sternum,  and  divides, 
behind  the  seventh  cartilage,  into  its  superior 
epigastric  and  musculo-phrenic  branches. 

The  mediastina.— Abscess  in  the  anterior 
mediastinum  may  have  developed  in  situ,  or  may 
have  spread  down  from  the  neck.  In  like  manner 
posterior  mediastinal  abscesses  may  arise  from 
diseases  of  the  adjacent  spine,  or  lymphatic 
glands,  or  may  be  due  to  the  spreading  down- 
wards of  a  retropharyngeal  or  retro-cesophageal 
collection  of  matter. 

The  employment  of  Rontgen  rays  in  the  diag- 
nosis of  intrathoracic  disease  has  greatly  enlarged 
our  knowledge  of  the  respiratory  movements  and 
relationships  of  the  thoracic  viscera.  In  Fig.  56 
(from  a  careful  drawing  given  by  Dr.  Halls 
Dally)  a  representation  is  given  of  the  more 
important  parts  seen  when  the  chest  is  examined 
in  an  axis  passing  from  the  right  nipple  to 
the  left  scapula  of  the  patient.  The  heart  and 
liver  appear  as  shadows,  moving  downwards  and 


x]       MOVEMENTS   OF  THORACIC  VISCERA     233 


forwards  in  inspiration,  upwards  and  backwards 
in  expiration.  As  the  diaphragm  descends,  and 
the  heart  moves  away  from  the  spine,  the  pos- 
terior mediastinum,  containing  the  aorta  and 
oesophagus,  appears  as  a  transradiant  triangle. 
With  inspiration,  too,  the  lungs  clear  up  and 
become  more  transparent.  The  anterior  medias- 
tinum also  is  seen  as  a  clear  space.  In  the 
superior  mediastinum  may  be  seen  the  arch  of 
the  aorta  as  it  passes  backwards  from  the  manu- 


DlAPH.    IN    EXPIRAT 


DlAPH.    IN    INSPIRAT. 


AORTIC  ARCH 
ANT.    MEDIASTINUM 


STERNUM 
HEART 


LIVER 


TRANSLUCENT  TRIANGLE 


Fig.  56.— Orthodiagram  of  the  thorax.       (After  Dr.  Halls 
Dally.) 

The  position  of  parts  is  shown  in  extreme  inspiration  ;  the  position 
of  the  diaphragm  and  liver  in  expiration  is  also  shown. 

brium  to  the  fourth  dorsal  vertebra.  In  the  in- 
dividual from  whom  the  diagram  was  constructed 
the  vertical  movement  of  the  diaphragm  amounted 
to  3  inches.  In  normal  respiration  the  vertical 
movement  varies  from  £  to  }  of  an  inch,  equal 
to  a  movement  of  a  rib-breadth. 

The  azygos  veins,  commencing  as  they  do  below 
in  the  lumbar  veins,  and  having  more  or  less  direct 
communications  with  the  common  iliac,  renal, 
and  other  tributaries  to  the  vena  cava,  are  able 
to  a  great  extent  to  carry  on  the  venous  circula- 


234  THE    THORAX  [CHAP. 

tion  in  cases^  of  obstruction  of  the  terminal  part 
of  the  superior  vena  cava.  In  this  they  are  as- 
sisted by  the  venae  comites  of  the  internal  mam- 
mary artery  and  epigastric  veins;  the  intraverte- 
bral  veins  also  become  greatly  enlarged,  and  serve 
as  anastomotic  channels  between  the  superior  and 
inferior  caval  systems. 

These  veins  are  apt  to  be  pressed  upon  by 
tumours  (such  as  enlarged  gland  masses)  de- 
veloped in  the  posterior  mediastinum,  and  to  pro- 
duce in  consequence  some  oedema  of  the  chest 
walls  by  engorgement  of  those  intercostal  veins 
which  they  receive.  Tumours  growing  in  the  pos- 
terior mediastinum  may  cause  trouble  by  press- 
ing upon  the  trachea  or  gullet,  or  by  disturbing 
the  vagus  nerve  or  the  cord  of  the  sympathetic. 
The  numerous  lymphatic  glands  which  surround 
the  trachea,  bronchi,  and  oesophagus  are  often  the 
seat  of  tuberculosis.  They  become  adherent  to 
these  organs  and  may  ulcerate  into  them. 

In  the  obscure  condition  named  status  lymplia- 
ticus  the  thymus  gland  is  usually  found  greatly 
enlarged.  It  occupies  the  anterior  mediastinum, 
being  placed  in  front  of  the  upper  part  of  the 
pericardium  and  great  vessels  of  the  heart,  and 
behind  the  part  of  the  sternum  and  the  costal  car- 
tilages which  lie  above  the  level  of  the  third  pair 
of  ribs.  Its  sides  are  covered  by  reflections  of  the 
mediastinal  pleura.  When  enlarged,  it  presses 
on  the  great  vessels  and  on  the  treachea  and 
bronchi,  causing  a  certain  degree  of  obstruction, 
but  not  enough  to  account  for  sudden  death  in 
cases  of  status  lymphaticus.  The  thymus  gland, 
composed  of  lymphoid  tissue,  reaches  its  maximum 
size  (36  grammes  =  1|  oz.)  about  the  eighteenth 
year;  thereafter  it  becomes  gradually  reduced  in 
size — more  so  in  men  than  in  women.  In  a  child 
at  birth  it  should  weigh  about  12  grm.  Its 
arteries  and  veins,  derived  from  the  internal 
mammary,  inferior  thyroid,  and  innominate  ves- 
sels, are  of  small  size.  The  gland  is  attached 
by  loose  connective  tissue  to  surrounding  struc- 


x]  THORACIC  DUCT  235 

tures.  Its  partial  or  even  complete  removal 
through  a  transverse  incision  made  between  the 
ends  of  the  clavicles  is  feasible  (p.  240).  Its 
functions  are  obscure,  but  it  has  a  direct  effect 
on  the  development  and  growth  of  bone.  For 
development,  see  Fig.  51,  p.  210. 

Thoracic  duel. — Krabbel  reports  a  case  of 
fracture  of  the  ninth  dorsal  vertebra  associated 
with  rupture  of  the  thoracic  duct.  The  patient 
died  in  a  few  days,  and  the  right  pleura  was 
found  to  contain  more  than  a  gallon  of  pure 
chyle. 

The  bodies  of  the  upper  lumbar  and  lower 
dorsal  vertebrae  are  frequently  the  site  of  tuber- 
culosis ;  so  are  the  apical  parts  of  the  lungs. 
Prof.  Wood- Jones  has  drawn  attention  to  the  close 
relationship  of  these  parts  to  the  thoracic  duct, 
and  to  the  possibility  of  a  tubercular  invasion 
from  the  alimentary  canal  being  conveyed  to 
these  sites  of  election  by  the  duct.  The  recepta- 
culum  chyli  is  formed  on  the  bodies  of  the 
first  and  second  lumbar  vertebrae,  from  which 
the  duct  ascends  in  the  posterior  mediastinum 
in  front  of  the  lower  dorsal  vertebrae.  In  cases 
of  cancer  of  the  stomach,  the  cervical  glands 
round  the  termination  of  the  thoracic  duct  may 
become  enlarged  by  secondary  growths  at  an  early 
stage  of  the  disease.  The  secondary  dissemination 
takes  place  by  means  of  the  thoracic  duct. 


PART  III.-THE  UPPER  EXTREMITY 

CHAPTER    XI 
THE    REGION   OF   THE    SHOULDER 

A  STUDY  of  the  region  of  the  shoulder  comprises 
the  clavicle,  the  scapula,  the  upper  end  of  the 
humerus,  and  the  soft  parts  that  surround  them, 
together  with  the  shoulder- joint  and  axilla. 

Surface  anatomy* — The  clavicle,  acromion 
process,  and  scapular  spine  are  all  subcutaneous, 
and  can  be  readily  felt.  In  the  upright  position, 
when  the  arm  hangs  by  the  side,  the  clavicle  is, 
as  a  rule,  not  quite  horizontal.  In  well-developed 
subjects  it  inclines  a  little  upwards  at  its  outer 
end.*  In  the  recumbent  posture,  the  weight  of  the 
limb  being  taken  off,  the  outer  end  rises  still 
higher  above  the  sternal  extremity.  The  degree 
of  the  elevation  can  be  best  estimated  by  a  study 
of  frozen  sections.  Thus,  in  making  horizontal 
sections  of  the  body,  layer  by  layer,  from  above 
downwards,  Braune  found  ^hat  by  the  time  the 
sterno-clavicular  articulation  was  reached,  the 
head  of  the  humerus  would  be  cut  across  in  the 
lateral  part  of  the  section  (Fig.  57) % 

The  deltoid  tubercle  of  the  clavicle  may,  if 
large,  be  felt  through  the  skin,  and  be  mistaken 
for  an  exostosis.  The  acromio:clavicular  joint  lies 
in  fche  plane  of  a  vertical  line  passing  up  the 
middle  of  the  front  of  the  arm.  A  prominence  is 

*  In  some  women,  in  the  feeble,  and  in  some  narrow-shouldered  men 
the  clavicle  may  be  horizontal,  or  its  outer  end  may  incline  downwards, 

23C7 


SURFACE  OF  THE  SHOULDER     237 

sometimes  felt  about  this  joint  in  place  of  the 
level  surface  that  it  should  present.  This  is  due 
to  an  enlargement  of  the  end  of  the  clavicle,  or 
to  a  thickening  of  the  nbro-cartilage  sometimes 
found  in  the  joint.  In  many  cases  it  has  ap- 
peared to  be  due  to  a  trifling  luxation  upwards 
of  the  clavicle,  depending  upon  some  stretch- 
ing of  the  ligaments.  It  is  certain  that  the  dry 
bone  seldom  shows  an  enlargement  such  as  to 
account  for  this  very  common  prominence  at  the 
acromial  articulation.  The  sternal  end  of  the 
clavicle  is  also,  in  muscular  subjects,  often  large 
and  unduly  prominent,  and  sufficiently  conspicu- 
ous to  suggest  a  lesion  of  the  bone  or  joint  when 
none  exists. 

The  roundness  and  prominence  of  the  point  of 
the  shoulder  depend  upon  the  development  of  the 
deltoid  and  the  position  of  the  upper  end  of  the 
humerus.  The  deltoid  hangs  like  a  curtain  from 
the  shoulder  girdle,  and  is  bulged  out,  as  it  were, 
by  the  bone  that  it  covers.  If  the  head  of  the 
humerus,  therefore,  be  diminished  in  bulk,  as  in 
some  impacted  fractures  about  the  anatomical 
neck,  or  be  removed  from  the  glenoid  cavity,  as  in 
dislocations,  the  deltoid  becomes  more  or  less  flat- 
tened, and  the  acromion  proportionately  promi- 
nent. The  part  of  the  humerus  felt  beneath  the 
deltoid  is  not  the  head,  but  the  tuberosities,  the 
greater  tuberosity  externally,  the  lesser  in  front. 
A  considerable  portion  of  the  head  of  the  bone 
can  be  felt  by  the  fingers  placed  high  up  in  the 
axilla,  the  arm  being  forcibly  abducted  so  as  to 
bring  the  head  in  contact  with  the  lower  part  of 
the  capsule.  The  head  of  the  humerus  faces  very 
much  in  the  direction  of  the  internal  or  medial 
epicondyle.  As  this  relation,  of  course,  holds 
good  in  every  position  of  the  bone,  it  is  of  value 
in  examining  injuries  about  the  shoulder,  and  in 
reducing  dislocations  by  manipulation,  the  epi- 
condyle being  used  as  an  index  to  the  position 
of  the  upper  end  of  the  bone. 

In    thin    subjects   the   outline   and   borders   of 


238  THE    UPPER    EXTREMITY  [CHAP. 

the  scapula  can  be  more  or  less  distinctly  made 
out,  but  in  fat  and  muscular  subjects  all  parts 
of  the  bone,  except  the  spine  and  acromion,  are 
difficult  of  access  in  the  ordinary  positions  of  the 
limb.  To  bring  out  the  superior  (medial)  angle 
and  vertebral  border  of  the  bone,  the  hand  of  the 
subject  should  be  carried  as  far  as  possible  over  the 
opposite  shoulder.  To  bring  out  the  inferior  angle 
and  axillary  border,  the  forearm  should  be  placed 
behind  the  back.  The  angle  formed  at  the  point 
of  junction  of  the  spine  of  the  scapula  and  the 
acromion  is  the  best  point  from  which  to  take 
measurement  of  the  arm,  the  tape  being  carried 
down  to  the  external  condyle  of  the  humerus.  The 
upper  border  of  the  scapula  lies  on  the  second 
rib,  its  lower  angle  on  the  seventh. 

When  the  arm  hangs  at  the  side  with  the 
palm  of  the  hand  directed  forwards,  the  acromion, 
external  or  lateral  epicondyle,  and  styloid  process 
of  the  radius  all  lie  in  the  same  line.  The  groove 
between  the  pectoralis  major  and  deltoid  muscles 
can  usually  be  made  out.  In  it  run  the  cephalic 
vein  and  a  large  branch  of  the  acromio-thoracic 
artery.  Near  the  groove,  and  a  little  below  the 
clavicle,  the  coracoid  process  may  be  felt.  This 
process,  however,  does  not  actually  present  in  the 
interval  between  the  two  muscles,  but  is  covered 
by  the  innermost  fibres  of  the  deltoid.  The  position 
of  the  coraco-acromial  ligament  may  be  defined, 
and  a  knife  thrust  through  the  middle  of  it 
should  strike  the  biceps  tendon  and  open  the 
shoulder-joint. 

When  the  arm  hangs  at  the  side  with  the  palm 
forwards,  the  bicipital  groove  (intertubercular 
sulcus)  may  be  defined  directly  below  the  acromio- 
clavicular  joint. 

Just  below  the  clavicle  is  a  depression,  the 
infraclavicular  fossa,  which  varies  considerably 
in  depth  in  different  subjects.  It  is  obliterated  in 
subcoracoid  dislocations  of  the  humerus,  in  frac- 
tures of  the  clavicle  with  displacement,  by  many 
axillary  growths,  and  by  some  inflammations  of 


xi]  SURFACE   OF  THE  AXILLA  239 

the  upper  part  of  the  thoracic  wall.  In  sub- 
clavicular  or  infracoracoid  dislocation  the  fossa 
is  replaced  by  an  eminence.  In  this  region,  at  a 
spot  to  the  inner  (medial)  side  of  the  coracoid 
process,  and  corresponding  nearly  to  the  middle 
of  the  clavicle,  the  pulsations  of  the  axillary 
artery  can  be  felt  against  the  second  rib.  Just 
below  the  clavicle  the  interspace  between  the 
sternal  and  clavicular  portions  of  the  pectoralis 
major  can  often  be  made  out. 

The  anterior  and  posterior  borders  of  the  axilla 
are  very  distinct.  The  anterior  border,  formed 
by  the  lower  edge  of  the  pectoralis  major,  follows 
the  line  of  the  fifth  rib.  The  depression  of  the 
armpit  varies,  other  things  being  equal,  with  the 
position  of  the  upper  limb.  It  is  most  deep  when 
the  arm  is  raised  from  the  side  at  an  angle  of 
about  45°,  and  when  the  muscles  forming  the  bor- 
ders of  the  space  are  in  a  state  of  contraction. 
As  the  arm  is  raised  above  the  horizontal  line  the 
depression  becomes  shallower,  the  head  of  the  bone 
projecting  into  the  space  and  more  or  less  obliter- 
ating it,  while  the  width  of  the  fossa  is  encroached 
upon  by  the  approximation  of  the  anterior^  and 
posterior  folds.  The  coracp-brachialis  muscle  itself 
forms  a  distinct  projection  along  the  humeral 
side  of  the  axilla  when  the  arm  is  raised  to  a 
right  angle  with  the  body.  If  the  arm  be  brought 
nearly  close  to  the  side,  the  surgeon's  hand  can 
be  thrust  well  up  into  the  axilla,  and  the  thoracic 
wall  explored  as  high  up  as  the  third  rib. 

The  axillary  glands  cannot  be  felt  when  they 
are  in  a  normal  condition.  The  central  set  lies 
beneath  the  axillary  tuft  of  hair. 

The  direction  of  the  axillary  artery,  when  the 
arm  is  raised  from  the  side,  is  represented  by  a 
line  drawn  from  the  middle  of  the  clavicle  to  the 
humerus  at  the  inner  (medial)  side  of  the  coracp- 
brachialis.  A  line  drawn  from  the  third  rib 
near  its  cartilage  to  the  tip  of  the  coracoid  pro- 
cess indicates  the  upper  border  of  the  pectoralis 
minor,  and  the  spot  where  this  line  crosses  the 


240  THE    UPPER    EXTREMITY  [CHAP. 

line  of  the  axillary  artery  points  out  the  position 
of  the  acromio-thoracic  artery.  A  line  drawn  from 
the  fifth  rib  near  its  cartilage  to  the  tip  of  the 
coracoid  process  indicates  the  lower  border  of 
the  pectoralis  minor,  and  the  position  of  the 
lateral  or  long  thoracic  artery  which  runs  along 
that  border.  The  line  of  the  subscapular  artery 
corresponds  to  the  lower  or  lateral  border  of 
the  subscapularis  muscle  along  which  it  runs, 
but  the  position  of  this  border  can  only  be  ap- 
proximately indicated  on  the  living  or  undissected 
subject. 

The  circumflex  (axillary)  nerve  and  posterior 
circumflex  artery  cross  the  humerus  in  a  hori- 
zontal line  that  is  about  a  finger's  breadth  above 
the  centre  of  the  vertical  axis  of  the  deltoid 
muscle.  This  point  is  of  importance  in  cases  of 
supposed  contusion  of  the  nerve.  These  various 
indications  of  the  positions  of  the  main  branches 
of  the  axillary  artery  are  made  while  the  arm 
hangs  in  its  natural  position  at  the  side.  The  dor- 
salis  scapulae  artery  (circumflex  scapular)  crosses 
the  axillary  border  at  a  point  corresponding  to 
the  centre  of  the  vertical  axis  of  the  deltoid. 

The  clavicle. — The  skin  over  the  clavicle  is 
loosely  attached,  and  is  easily  displaced  about  the 
bone.  This  circumstance  may  serve  to  explain 
why  the  skin  so  often  escapes  actual  wound  in 
contusions  of  the  clavicular  region,  and  in  part 
explains  the  infrequency  of  penetration  of  the 
integument  in  fractures  of  the  clavicle.  The 
three  supraclavicular  nerves  that  cross  the  clavicle 
are  branches  of  the  third  and  fourth  cervical 
nerves,  and  it  is  well  to  note  that  pain  over  the 
collar-bone  is  sometimes  a  marked  feature  in 
disease  of  the  upper  cervical  spine.  This  symp 
torn  is  then  due  to  irritation  of  these  nerves  at  their 
points  of  exit  from  the  spinal  canal.  A  communica- 
tion between  the  external  jugular  and  cephalic 
veins  is  occasionally  seen  to  cross  the  clavicle. 

Beneath  the  clavicle  the  great  vessels  and  the 
great  nerve-cords  lie  upon  the  first  rib.  The  vein 


xi]  THE   CLAVICLE  241 

is  the  most  internal,  and  occupies  the  acute  angle 
between  the  collar-bone  and  the  first  rib.  It  will 
be  seen  that  growths  from  the  bone  may  readily 
press  upon  these  important  structures,  and  that 
the  vein,  from  its  position,  as  well  as  from  the 
slighter  resistance  that  it  offers,  is  likely  to  be 
the  first  to  be  compressed.  These  structures  have 
also  been  wounded  by  fragments  of  bone  in 

CLAVICLE 
STERNO     MYOIO     \ 
PHRENIC    N,      \\     LT  CAftOT/0    ARTERY 

1*7   fi IB.       \     \\    \LTINNOM.VEIN 
l_TSUBCLAV.VEIN\     \    \\\    \9rf**O-TMYfHH 
PCCTORALIS   MAJOR      \      \     \\\\\   \MANUBR/UM 
fCCTOflALIS   MINOR 

COKACO-BffACM/ALlS 
A  BICEPS  \ 

HZAOOFHUMERUS 


Fig.  57.  — Horizontal  section  at  the  level  of  the  left 
shoulder-joint,  to  show  the  lie  of  the  parts  in  the 
vicinity  of  the  left  clavicle.  (After  Bmune.) 

fracture  of  the  clavicle.  Fortunately,  between 
the  clavicle  and  these  large  nerves  and  vessels 
the  subclavius  muscle  is  interposed.  This  muscle 
is  closely  attached  to  the  under  surface  of 
the  bone,  is  enveloped  in  a  dense  fascia,  and 
forms  one  of  the  chief  protections  to  the  ves- 
sels in  case  of  fracture.  This  interposing  p^ad 
of  muscle  is  also  of  great  service  in  resection 
operations.  Behind  the  clavicle  the  following 
structures  may  be  noted  (Fig.  57),  viz.  the  in- 


242  THE    UPPER    EXTREMITY  [CHAP. 

nominate,  subclavian,  and  external  jugular  veins, 
the  subclavian,  suprascapular  (transverse  scapu- 
lar), and  internal  mammary  arteries,  the  cords 
of  the  brachial  plexus,  the  phrenic  nerve  and 
long  thoracic  nerve  (nerve  of  Bell),  the  thoracic 
duct,  the  omo-hyoid,  scalene,  sterno-hyoid,  and 
sterno-thyroid  muscles,  and  the  apex  of  the  lung. 
The  sternal  end  of  the  bone  is  not  far  removed 
from  the  innominate  or  left  carotid  artery,  the 
vagus  and  recurrent  nerves,  the  trachea,  and 
the  oesophagus. 

These  relations  of  the  clavicle  are  given  to  show 
the  dangers  in  the  way  of  partial  or  complete 
resections  of  the  bone.  The  difficulties  and  risks 
of  the  operation  increase  as  one  progresses  from 
the  acromial  to  the  sternal  end.  Resection  of  the 
acromial  third  of  the  bone  is  comparatively  easy, 
but  resection  of  the  sternal  portion  is  difficult 
and  dangerous.  The  entire  clavicle  has  been  re- 
moved with  success,  and  the  operation  has  been 
followed  by  less  impairment  of  the  arm  movements 
than  would  be  imagined. 

The  clavicle  forms  the  sole  direct  bony  con- 
nexion between  the  upper  limb  and  the  trunk, 
and  in  severe  accidents,  this  connexion  being 
broken  through,  it  is  possible  for  the  extremity 
to  be  torn  off  entire.  Thus  Billrpth  reports  the 
case  of  a  boy  aged  14,  whose  right  arm,  with 
the  scapula  and  clavicle,  was  so  torn  from  the 
trunk  by  a  machine  accident  that  it  was  only 
attached  by  a  strip  of  skin  2  inches  wide.  Other 
similar  cases  of  avulsion  of  the  limb  have  also 
been  reported. 

Fractures  of  the  clavicle. — The  clavicle  is  more 
frequently  broken  than  is  any  other  single  bone 
in  the  body.  This  is  due  to  the  fact  that  it 
is  the  only  bony  connexion  between  the  upper 
extremity  and  the  trunk,  and  is  often  exposed 
to  violence.  Force  can  be  brought  to  bear  on  it 
by  means  of  a  long  lever,  the  upper  extremity. 
The  common  fracture,  that  due  to  indirect  violence, 
is  oblique,  and  very  constant  in  its  position,  viz. 


xi]  FRACTURES   OF  THE   CLAVICLE          243 

at  the  outer  end  of  the  middle  third  of  the  bone. 
So  closely  is  the  outer  third  of  the  clavicle  bound 
by  ligaments  to  the  coracoid  and  acromion  pro- 
cesses that  it  may  be  regarded  as  part  of  the 
scapula.  Hence  the  impact  resulting  from  a  fall 
on  the  shoulder  is  transferred  to  the  clavicle  at 
the  junction  of  its  outer  and  middle  thirds.  The 
bone  breaks  at  the  point  where  the  force  is  trans- 
ferred to  the  clavicle  from  the  scapula.  The  posi- 
tion of  the  coraco-clavicular  ligaments  is  no  doubt 
of  the  greatest  import  in  localizing  the  fracture 
in  this  position,  since  a  clavicle  experimentally 
subjected  to  longitudinal  compression  does  not 
break  at  this  spot  (Bennett). 

The  displacement  that  occurs  is  as  follows.  The 
inner  fragment  remains  unchanged  in  position,  or 
its  outer  end  is  drawn  a  little  upwards  by  the 
sterno-mastoid.  It  will  be  seen  that  any  action  of 
this  muscle  would  be  resisted  by  the  pectoralis 
major  and  the  costo-clavicular  (rhomboid)  liga- 
ment. The  outer  fragment  undergoes  a  threefold 
displacement.  (1)  It  is  carried  directly  down- 
wards. This  is  effected  mainly  by  the  weight 
of  the  limb  aided  by  the  pectoralis  minor,  the 
lower  fibres  of  the  pectoralis  major,  and  the 
latissimus  dorsi.  (2)  It  is  carried  directly  in- 
wards by  the  muscles  that  pass  from  the  trunk 
to  the  shoulder,  viz.  the  levator  scapulae,  the 
latissimus  dorsi,  and  especially  by  the  pec- 
torals. (3)  The  fragment  is  rotated  in  such  a 
way  that  the  outer  end  projects  forwards,  the 
inner  end  backwards.  This  rotation  is  brought 
about  mainly  by  the  two  pectorals,  assisted  pro- 
minently by  the  serratus  magnus  (anterior).  The 
normal  action  of  this  latter  muscle  is  to  carry  the 
scapula  forwards,  and  the  clavicle,  acting  as  a 
kind  of  outrigger  to  keep  the  upper  limb  at  a 
proper  distance  from  the  trunk,  moves  forwards 
at  the  same  time  and  keeps  the  scapula  direct. 
When  this  outrigger  is  broken  the  serratus  can  no 
longer  carry  the  scapula  directly  forwards.  The 
bone  tends  to  turn  towards  the  trunk,  and  the 


244  THE    UPPER    EXTREMITY  [CHAP. 

point  of  the  shoulder  is  therefore  seen  to  move 
inwards  as  well  as  forwards.  The  fragments  in 
this  fracture  must  consequently  overlap,  and  as 
the  displacement  is  difficult  to  remedy,  it  follows 
that  in  no  bone  save  the  femur  is  shortening  so 
uniformly  left  as  after  an  oblique  fracture  of  the 
clavicle.  The  degree  of  shortening  very  seldom 
exceeds  an  inch.  The  deformity  associated  with 
this  fracture  is  well  corrected  when  the  patient 
assumes  the  recumbent  position.  In  this  posture, 
the  weight  of  the  limb  being  taken  off,  the  down- 
ward displacement  is  at  once  remedied.  The 
point  of  the  shoulder  falling  back  also  tends  to 
relieve  in  part  the  inward  displacement,  and  the 
rotation  of  the  outer  fragment  forwards.  It  is 
through  the  scapula,  however,  that  these  two  latter 
displacements  are  in  the  main  removed.  In  the 
recumbent  posture  the  scapula  is  pressed  closely 
against  the  thorax,  with  the  result  that  its  outer 
extremity  (and  with  it,  of  course,  the  outer  frag- 
ment of  the  clavicle)  is  dragged  outwards  and 
backwards.  Some  surgeons,  recognizing  this  im- 
portant action  of  the  scapula  in  remedying  the 
displacement  in  these  cases,  strap  the  scapula 
fi.rm.ly  against  the  trunk,  while  at  the  same  time 
they  elevate  the  arm. 

Fractures  due  to  direct  violence  are  usually 
transverse,  and  may  be  at  any  part  of  the  bone. 
When  about  the  middle  third  they  present  the 
displacement  just  described.  When  the  fracture 
is  between  the  conoid  and  trapezoid  ligaments  no 
displacement  is  possible.  When  beyond  these  liga- 
ments, the  outer  end  of  the  outer  fragment  is  car- 
ried forwards  by  the  pectorals  and  serratus,  and 
its  inner  end  is  a  little  drawn  up  by  the  trapezius. 
In  this  fracture  there  is  no  general  displacement 
downwards  of  the  outer  fragment,  since  it  can- 
not move  in  that  direction  unless  the  scapula  go 
with  it,  and  the  scapula  remains  fixed  by  the 
coraco-clavicular  ligaments  to  the  inner  fragment 
of  the  clavicle. 

The  clavicle  may  be  broken  by  muscular  vio- 


xi]  FRACTURES   OF  THE  CLAVICLE          245 

lence  alone.  Polaillon,  from  a  careful  analysis  of 
the  reported  cases,  concludes  that  the  muscles  that 
break  the  bone  are  the  deltoid  and  the  clavicular 

Eart  of  the  great  pectoral.  In  no  case  does  the 
racture  appear  to  have  been  produced  by  the 
sterno-mastoid  muscle.  The  commonest  movements 
producing  fracture  appear  to  be  violent  move- 
ments of  the  limb  forwards  and  inwards,  or  up- 
wards. These  fractures  are  usually  about  the 
middle  of  the  bone,  and  show  no  displacement 
other  than  that  of  both  fragments  forwards,  i.e. 
in  the  direction  of  the  fibres  of  the  two  muscles 
first  named.  The  clavicle  is  more  frequently  the 
seat  of  green-stick  fracture  than  is  any  other  bone 
in  the  body ;  indeed,  one-half  of  the  cases  of  broken 
collar-bone  occur  before  the  age  of  5  years. 

A  reference  to  the  relations  of  the  bone  will 
show  that  important  structures^  may  be  wounded 
in  severe  fractures  associated  with  much  displace- 
ment and  with  sharp  fragments  (see  ^Fig.  57). 
Several  cases  are  reported  of  paralysis  of  the 
upper  limb  (as  a  rule  incomplete)  following  upon 
fracture  of  this  bone.  In  some  cases  this  symp- 
tom was  due  to  actual  compression  or  tearing 
of  some  of  the  great  nerve-cords  by  the  displaced 
fragments.  In  other  cases  the  nerve  injury,  while 
due  to  the  original  accident,  was  yet  independent 
of  the  broken  clavicle.  Paralysis  of  the  biceps, 
brachialis,  andbrachio-radialis  (supinator  longus), 
muscles  supplied  through  the  upper  (lateral)  cord, 
may  result  from  heavy  weights  being  carried 
on  the  shoulder  (Fig.  85,  p.  392).  Cases  are  re- 
ported of  wound  of  the  subclavian  artery,  of  the 
subclavian  vein,  of  the  internal  jugular  vein, 
and  of  the  acromio-thoracic  artery.  In  several 
instances  the  fracture  has  been  associated  with 
wound  of  the  lung,  with  or  without  a  fracture 
of  the  upper  ribs. 

The  clavicle  begins  to  ossify  before  any  bone  in 
the  bodv.  At  birth  the  entire  shaft  is  bony,  the 
two  ends  being  still  cartilaginous.  There  is  one 
cpiphysis  for  its  sternal  end,  which  appears 


246  THE    UPPER    EXTREMITY  [CHAP. 

between  the  eighteenth  and  twentieth  years,  and 
joins  the  shaft  about  25.  It  is  a  mere  shell,  is 
closely  surrounded  by  the  ligaments  of  the  sternal 
joint,  and  cannot,  therefore,  be  well  separated  by 
accident.*  In  cases  where  the  clavicle  is  described 
as  congenitally  absent,  the  membrane-formed  part 
of  the  bone  is  represented  by  a  ligamentous 
cord;  the  cartilage-formed  extremities  are  repre- 
sented by  bony  nodules.  Defective  ossification 
of  the  clavicle  is  commonly  associated  with  an 
imperfect  ossification  of  the  membrane-formed 
bones  of  the  skull,  the  condition  being  known 
as  cranio-cleido-dysostosis,  a  disease  of  which 
D.  Fitzwilliams  has  collected  60  examples.  The 
subjects  of  this  disease,  owing  to  the  ligamentous 
condition  of  the  greater  part  of  the  clavicle, 
are  able  to  approximate  their  shoulder  to  a 
remarkable  ^extent.  The  defect  in  the  clavicle 
may  be  so  limited  as  to  resemble  a  fracture. ^ 

Sterno-claviciilar  joint.  —  Although  this  is 
the  only  articulation  that  directly  connects  the 
upper  limb  with  the  trunk,  yet  it  is  possessed  of 
such  considerable  strength  that  luxation  at  the 
joint  is  comparatively  rare.  The  amount  of  move- 
ment in  the  joint  depends  to  a  great  extent  upon 
the  lack  of  adaptability  between  the  facets  on  the 
sternum  and  the  sternal  end  of  the  clavicle.  ^The 
disproportion  between  these  parts  is  maintained 
by  the  interarticular  cartilage,  which  reproduces 
only  the  outline  of  the  clavicular  surface.  The 
cavity  of  the  joint  is  V-shaped,  since  the  clavicle 
only  touches  the  socket  at  its  inferior  angle  when 
the  arm  hangs  by  the  side.  When  the  arm  is 
elevated,  however,  the  two  bones  are  brought  in 
more  immediate  contact,  and  the  joint  cavity  be- 
comes a  mere  slit.  Thus,  in  disease  of  this  articu- 
lation it  will  be  found  that  of  all  movements  of 
the  joint  the  movement  of  the  limb  upwards  is 

*  Mr.  Heath  (Lancet,  Nov.  18,  1882)  reports  a  case  which  is  probably 
unique.  It  concerns  a  lad  aged  14,  who,  in  the  act  of  bowling  at  cricket, 
tore  the  clavicle  away  from  its  epiphyseal  cartilage,  which  re-mained 
in  situ.  The  muscle  producing  the  accident  was  apparently  the  pectoralis 
major. 


xi]  STERNO-OLAVICULAR  JOINT  247 

the  most  constant  in  producing  pain.  The  joint 
is  supplied  by  the  suprasternal  branch  of  the 
descending  cervical  nerves. 

The  movements  permitted  at  this  joint  are 
limited,  owing  to  the  anterior  and  posterior 
sterno-clavicular  ligaments  being  moderately 
tense  in  all  positions  of  the  clavicle.  Movement 
forwards  of  the  clavicle  on  the  sternum  is  checked 
by  the  posterior  ligament,  and  resisted  by  the  an- 
terior ligament.  This  latter  ligament  is  more  lax 
and  less  substantial  than  is  the  posterior  band. 
Its  weakness  serves  in  part  to  explain  the  fre- 
quency of  the  dislocation  forwards. 

Movement  of  the  clavicle  backwards  on  the 
sternum  is  checked  by  the  anterior  ligament,  while 
the  passage  of  the  head  of  the  bone  is  resisted 
by  the  powerful  posterior  band.  The  movement 
is  also  opposed  by  the  costo-clavicular  ligament. 
To  produce,  therefore,  a  dislocation  backwards 
considerable  force  must  be  used. 

Disease  of  the  sterno=clavicular  joint.  —  This 
articulation  is  really  divided  into  two  joints  by 
the  interarticular  cartilage,  each  being  provided 
with  a  distinct  synovial  membrane. 

These  joints  are  liable  to  the  ordinary  maladies 
of  joints,  and  it  would  appear  that  the  disease 
may  commence  in,  and  be  for  some  time  limited 
to,  only  one  of  the  synovial  sacs.  In  time  the 
whole  articulation  usually  becomes  involved,  but 
even  in  advanced  cases  the  mischief  is  sometimes 
restricted  to  the  synovial  cavity  on  one  side  of  the 
cartilage.  According  to  some  authors,  this  joint 
is  more  frequently  involved  in  pyaemia  than  is  any 
other.  When  effusion  has  taken  place  into  the 
sterno-clavicular  joint,  and  especially  after  sup- 
puration has  ensued,  the  swelling  usually  makes 
itself  evident  in  front,  owing  to  the  fact  that  the 
anterior  sterno-clavicular  ligament  is  the  thinnest 
and  least  resisting  of  the  ligamentous  structures 
about  the  articulation.  For  the  same  reason  the 
pus  usually  escapes  from  the  anterior  surface 
when  it  discharges  itself  spontaneously. 


248  THE    UPPER    EXTREMITY  [CHAP. 

Dislocations  of  the  sterno-clavicular  joint— The 

clavicle  may  be  dislocated  from  the  sternum  in 
one  of  three  directions,  which,  given  in  order 
of  frequency,  are  :  (1)  forwards,  (2)  backwards, 
(3)  upwards.  The  relative  frequency  of  these  dis- 
locations can  be  understood  from  what  has  been 
already  said  as  to  the  action  of  the  ligaments  in 
restricting  movements. 

'  Acromio-clavicular  joint.— This  articulation 
is  shallow,  and  the  outlines  of  the  two  bones  that 
enter  into  its  formation  are  such  that  no  obstacle 
is  offered  to  the  displacement  of  the  clavicle  from 
the  acromion.  The  joint,  indeed,  depends  for  its 
strength  almost  entirely  upon  its  ligaments.  The 
plane  of  the  joint  would  be  represented  by  a  line 
drawn  from  above  downwards  and  inwards  be- 
tween the  two  bones.  This  inclination  of  the  joint- 
surfaces  serves  to  explain  the  fact  that  the  usual 
luxation  of  this  part  takes  the  form  of  a  dis- 
placement of  the  clavicle  upwards  on  to  the 
acromion. 

As  the  movements  permitted  in  this  joint  may 
be  impaired  by  accident  or  disease,  it  is  well  to 
note  the  part  the  articulation  takes  in  the  move- 
ments of  the  extremity.  The  scapula  (and  with  it, 
of  course,  the  arm),  as  it  glides  forwards  and 
backwards  upon  the  thorax,  moves  in  the  arc  of  a 
circle  whose  centre  is  at  the  sterno-clavicular 
joint,  and  whose  radius  is  the  clavicle.  As  the 
bone  moves  forwards  it  is  important,  for  reasons 
to  be  immediately  given,  that  the  glenoid  cavity 
should  also  be  directed  obliquely  forwards.  This 
latter  desirable  condition  t  is  brought  about  by 
means  of  the  acromio-clavicular  joint.  Without 
this  joint  the  whole  scapula  as  it  passed  forwards 
with  the  outer  end  of  the  clavicle  would  precisely 
follow  the  line  of  the  circle  above  mentioned,  and 
the  glenoid  cavity  would  look  in  an  increasingly 
inward  direction.  It  is  essential  that  the  surface 
of  the  glenoid  cavity  should  be  maintained  as  far 
as  possible  at  right  angles  to  the  long  axis  of  the 
humerus.  When  these  relations  are  satisfied,  the 


xi]  ACROMIO-CLAVIGULAR  JOINT  249 

humerus  has  the  support  behind  of  a  stout  sur- 
face of  bone,  and  it  is  partly  to  obtain  the  value 
of  this  support  that  the  boxer  strikes  out  from 
the  side,  i.e.  with  his  humerus  well  backed  up  by 
the  scapula.  If  there  were  no  acromio-clavicular 
joint  the  glenoid  fossa  would  offer  little  support 
to  the  humerus  when  the  limb  was  stretched  for- 
wards, and  a  blow  given  with  the  limb  in  that 
position,  or  a  fall  upon  the  hand  under  like  con- 
ditions, would  tend  to  throw  the  humerus  against 
the  capsule  of  the  shoulder-joint,  and  so  produce 
dislocation.  Normally,  therefore,  as  the  scapula 
and  arm  advance,  the  angle  between  the  acromion 
and  the  adjacent  portion  of  the  clavicle  becomes 
more  and  more  acute,  and  the  glenoid  fossa  is 
maintained  with  a  sufficiently  forward  direction 
to  give  substantial  support^to  the  humerus.*  It 
will  thus  be  seen  that  rigidity  of  this  little  joint 
may  be  a  cause  of  insecurity  in  the  articulation 
of  the  shoulder,  and  of  weakness  in  certain  move- 
ments of  the  limb.  There  is  also  movement  in 
this  joint  as  the  arm  is  lifted  towards  the 
head,  the  angle  between  the  clavicle  and  axillary 
border  becoming  more  acute  as  the  shoulder  is 
elevated. 

Dislocations  of  the  acromio-clavicular  joint.— 
The  clavicle  may  be  displaced  upwards  on  to 
the  acromion,  or  downwards  beneath  it.  Polaillon 
has  collected  38  cases  of  the  former  luxation, 
and  6  only  of  the  latter.  This  disproportion  is, 
in  the  main,  explained  by  the.  direction  of  the 
articulating  surfaces  of  the  joint. 

Scapula. — At  the  posterior  or  dorsal  aspect 
of  the  bone  the  muscles  immediately  above  and 
below  the  spine  are  bound  down  by  the  deep 
fascia.  Thus,  the  supraspinatus  muscle  is  en- 
closed in  a  fascia  that,  being  attached  to  the  bone 
all  round  the  origin  of  the  muscle,  forms  a  cavity 
open  only  towards  the  insertion  of  the  muscle. 

The  infraspinatus  and  teres  minor  muscles  are 

*  For  an  excellent  account   of  the  mechanism  of  these  joints,  see 
Morris's  "  Anatomy  of  the  Joints,"  p.  202  et  seq. 


250  THE    UPPER    EXTREMITY  [CHAP. 

also  enclosed  in  a  distinct,  but  much  denser,  fascia 
that  is  attached  to  the^bone  beyond  these  muscles, 
and  blends  in  front  with  the  deltoid  sheath  so  as 
to  form  a  second  enclosed  space.  The  arrange- 
ment of  these  fasciae  serves  to  explain  the  trifling 
amount  of  ecchymosis  that  usually  follows  upon 
fractures  of  the  scapular  blade.  The  extravasa- 
tion of  blood  about  the  fracture  is  bound  down 
by  the  fasciae  over  these  muscles,  and  is  unable, 
therefore,  to  reach  the  surface. 

Movements  of  the  scapula. — In  lifting  the  arm 
from  the  side  to  a  vertical  position  over  the 
head  a  double  movement  takes  place— (1)  between 
the  scapula  and  the  trunk;  (2)  between  the 
humerus  and  the  scapula,  at  the  shoulder-joint. 
The  extent  of  the  movement  in  the  first  joint 
is  only  about  45°,  whereas  in  the  second  it  is 
about  100°.  The  one  joint  is  accessory  to  the 
other.  Hence,  in  ankylosis  of  the  shoulder- joint, 
we  can  still  attain  a  certain  degree  of  abduction 
and  adduction  of  the  arm,  the  whole  upper 
extremity  moving  with  the  rotating  scapula.  To 
obtain  this  result  the  arm  must  be  abducted 
from  the  side  before  ankylosis  sets  in.  As  the 
extremity  is  raised  the  scapula  undergoes  a  free 
rotatory  movement,  its  vertebral  border  passing 
from  an  approximately  vertical  to  an  approxi- 
mately horizontal  position.  At  the  commencement 
of  the  movement,  until  the  arm  has  ascended 
35°  from  the  side,  the  angle  of  the  scapula 
is  practically  stationary;  during  this  stage  the 
scapula  is  fixed  and  maintained  in  position  by 
the  trapezius,  rhomboids,  and  serratus  magnus. 
If  the  trapezius  is  paralysed,  as  may  result  from 
accidental  section  of  the  accessory  (spinal  acces- 
sory) nerve  in  removing  glands  from  the  neck, 
the  inferior  angle  and  vertebral  border  project 
backwards,  under  the  weight  of  the  raised  arm; 
the  acromial  region  of  the  shoulder  drops  down- 
wards and  forwards.  When  the  arm  passes 
beyond  35°,  the  serratus  magnus  comes  into 
action,  and  the  inferior  angle  of  the  scapula 


xi]  FRACTURES   OF  THE   SCAPULA  251 

moves  rapidly  forwards.  If  the  nerve  to  this 
muscle  be  paralysed  (the  long  thoracic  from 
5,  6,  7  c.)  or  if  its  antagonists — the  rhomboids—- 
which are  also  then  in  action,  be  paralysed  (nerve 
from  5  c.),  then  the  angle  and  posterior  border 
of  the  scapula  become  prominent  or  "  winged  "- 
evidence  of  the  paralysis  of  these  muscles.  Thus 
"winging"  of  the  scapula  at  the  commencement 
of  the  movement  indicates  paralysis  of  the  trape- 
zius;  if  it  occurs  after  the  movement  is  well  begun, 
then  the  serratus  magnus  is  affected. 

Fractures  of  the  scapula,  and  especially  of  the 
body  of  the  bone,  are  not  common,  owing  to  the 
mobility  of  the  part  and  the  thick  muscles  that 
cover  in  and  protect  its  thinner  portions.  It  rests 
also  upon  a  soft  muscular  pad,  and  derives,  no 
doubt,  additional  security  from  the  elasticity  of 
the  ribs. 

The  most  common  lesion  is  a  fracture  of  the 
acromion  process.  This  is  often  but  a  separation 
of  the  epiphysis.  There  are  two,  sometimes  three, 
epiphyseal  centres  for  the  acromion.  Ossification 
appears  in  them  about  puberty,  and  the  entire 
epiphysis  joins  with  the  rest  of  the  bone  from  the 
twenty-second  to  the  twenty-fifth  year.  Several 
cases  of  supposed  fracture  of  the  acromion  united 
by  fibrous  tissue  are  probably  but  instances  of  an 
imperfectly-united  epiphysis,  and  may  have  been 
independent  of  injury.  In  5  bodies  out  of  40 
Symington  found  the  acromial  epiphysis  united 
to  the  spine  by  a  fibrous  union,  and  from  the 
statistics  of  other^  observers  it  appears  that  this 
is  the  case  in  quite  10  per  cent,  of  adults.  In 
fractures  of  the  process  much  displacement  is 
quite  uncommon,  owing  to  the  dense  fibrous  cover- 
ing the  bone  derives  from  the  two  muscles  attached 
to  it.  The  coracoid  process  may  present  a  genuine 
fracture,  or  may  be  separated  as  an  epiphysis. 
As  an  epiphysis,  it  joins  the  main  bone  about 
the  age  of  17.  The  supraglenoid  tubercle,  from 
which  the  long  head  of  the  biceps  takes  its  origin, 
is  part  of  the  coracoid  epiphysis.  In  spite  of 


252  THE    UPPER    EXTREMITY  [CHAP. 

the  powerful  muscles  that  are  attached  to  the 
coracoid,  the  displacement  Is  usually  slight,  inas- 
much as  the  coraco-clavicular  ligaments  are  seldom 
torn.  These  ligaments,  it  may  be  noted,  are 
attached  to  the  base  of  the  process.  In  some  few 
cases  the  process  has  been  torn  off  by  muscular 
violence. 

Among  the  more  usual  fractures  of  the  body  of 
the^  scapula  is  a  transverse  or  oblique  fracture 
of  its  blade  below  the  spine.  Owing  to  the  infra- 
spinatus,  subscapularis,  and  other  muscles  being 
attached  to  both  fragments,  none  but  a  trifling 
displacement  is  usual.  A  fracture  may  occur 
through  the  surgical  neck.  The  surgical  neck 
is  represented  by  a  narrowed  part  of  the  bone 
behind  the  glenoid  fossa,  and  in  the  line  of 
the  suprascapular  notch  (incisura  scapularis). 
The  smaller  fragment  will,  therefore,  include  the 
coracoid  process;  the  larger,  the  acromion. 

Tumours  of  the  scapula. — Tumours  of  various 
kinds  grow  from  the  scapula,  and  mainly  from 
the  spongy  parts  of  the  bone — viz.  the  spine, 
the  neck,  and  the  inferior  angle.  It  may  be 
sufficient  to  excise  the  scapula  alone,  but  it  must 
be  remembered  that  the  main  fulcrum  on  which 
the  upper  extremity  rotates  is  then  removed.  It 
is  therefore  more  usual  in  such  cases  to  perform 
an  inter scapulo-thoracic  amputation,  which  is 
usually  done  for  malignant  tumours  involving 
structures  in  the  neighbourhood  of  the  shoulder- 
joint.  In  this  operation  the  upper  extremity, 
including  the  scapula  and  the  clavicle  beyond 
the  origin  of  the  sterno-mastoid,  is  removed.  An 
elliptical  incision  is  made  in  front  of  and  behind 
the  shoulder,  the  upper  end  of  the  ellipse  lying 
on  the  clavicle,  the  lower  at  the  angle  of  the 
scapula.  The  operation  is  begun  at  the  clavicle 
so  as  to  secure  the  axillary  vessels.  The  artery 
is  tied  before  the  vein  so  that  the  limb  may 
continue  to  empty  its  blood  into  the  circulation. 
The  main  vessels  to  be  noted  in  connexion  with 
this  operation  are  the  suprascapular  (transverse 


xi]  THE   AXILLA  253 

scapular)  at  the  superior  border  of  the  bone, 
the  posterior  scapular  (branch  of  the  transverse 
cervical)  about  the  vertebral  border,  the  sub- 
scapular  running  along  the  lower  border  of  the 
subscapularis  muscle,  the  dorsalis  scapulae  crossing 
the  axillary  edge  of  the  bone,  and  the  acromial 
branches  of  the  acromio-thoracic  artery. 

The  axilla. — The  axilla  may  be  regarded  sur- 


CORACOIO 
ACROMION 


GT.  TUB. 
BICIP.  GROOVE 


CIRCIHVI.  N. 
DELTOID 


Fig.  58. — Relationship  of  the  axillary  artery  and  brachial 
plexus  to  the  shoulder-joint  and  axilla. 

gically  as  a  passage  between  the  neck  and  the  upper 
limb  (Fig.  58).  Axillary  tumours  and  abscesses  may 
spread  up  into  the  neck,  and  in  like  manner  cer- 
vical growths  and  purulent  collections  may  extend 
to  the  armpit.  The  skin  forming  the  base  of  the 
axilla  is  provided  with"  many  short  hairs  and 
with  numerous  sebaceous  and  sudoriparous  glands. 
In  this  integument  small  superficial  abscesses  are 
often  met  with,  that  arise  usually  from  suppura- 
tion of  these  glandular  structures,  and  that  are 


254  THE    UPPER    EXTREMITY  [CHAP. 

brought  about  by  the  friction  of  the  skin  against 
the  clothing.  Owing  to  the  tendency  of  the  axil- 
lary integument  to  become  chafed  and  inflamed 
under  friction,  the  axilla  is  not  a  good  locality  to 
select  for  the  use  of  the  mercurial  inunction  as 
applied  in  syphilis.  Beneath  the  skin  and  super- 
ficial fascias  is  the  axillary  fascia,  and  beyond  this 
membrane  is  the  axillary  space.  The  connective 
tissue  with  which  the  axillary  space  is  mainly 
occupied  is  very  loose,  and,  while  this  laxity 
favours  greatly  the  free  movement  of  the  arm,  it 
at  the  same  time  permits  of  the  formation  of  large 
purulent  collections  and  immense  extravasations 
of  blood. 

It  is  important  to  remember  the  disposition 
of  the  fasciae  about  this  region.  There  are  three 
layers  principally  concerned.  (1)  The  deep  pec- 
toral fascia  which  covers  in  and  encloses  the  pector- 
alis  major.  (2)  The  clavi-pectoral  fascia  which, 
adherent  above  to  the  clavicle,  fills  in  the  space 
between  that  bone  and  the  pectoralis  minor,  then 
splits  to  invest  this  muscle,  and  joins  the  deep 
pectoral  layer  at  the  anterior  fold  of  the  axilla 
to  form  with  it  the  axillary  fascia.  The  upper 
part  of  this  fascia  is  generally  known  as  the  costo- 
coracoid  membrane.  The  whole  membrane  is  some- 
times known  also  as  the  "  suspensory  ligament  of 
the  axilla,"  since  it  draws  up  the  axillary  fascia 
towards  the  clavicle,  and  is  mainly  instrumental 
in  producing  the  "  hollow  "  of  the  armpit.  (8^ 
The  axillary  fascia  which  is  formed  by  the  union  of 
the  two  preceding  fasciae,  and  stretches  across  the 
base  of  the  axilla  from  its  anterior  to  its  posterior 
fold.  It  is  thinnest  under  the  axillary  hairs. 

Abscess  about  the  axillary  region  may  be  formed 
beneath  the  pectoralis  major,  or  between^the  two 
pectoral  muscles,  or  beneath  the  pectoralis  minor 
and  clavi-pectoral  fascia,  and  therefore  in  the 
axillary  space.  The  loose  tissue  of  the  axillary 
space  allows  the  formation  of  a  large  abscess 
cavity.  The  abscess  as  it  fills  the  axilla  pushes 
forwards  the  pectoralis  major,  more  or  less  obli- 


xi]  AXILLARY   ABSCESS  255 

terates  the  hollow  of  the  armpit,  thrusts  back 
the  scapula,  and  widens  the  angle  between  the 
serratus  magnus  (anterior)  and  the  subscapularis 
muscles.  There  is  a  great  tendency,  therefore, 
for  unrelieved  abscesses  to  extend  upwards  into 
the  neck,  that  being  the  direction  in  which  the 
least  amount  of  resistance  is  encountered.  From 
the  neck  the  purulent  collection  may  extend  into 
the  mediastinum.  In  one  case  an  axillary  abscess, 
set  up  by  shoulder-joint  disease,  perforated  the 
first  intercostal  space  and  set  up  fatal  pleurisy. 

In  opening  an  axillary  abscess,  and,  indeed,  in 
most  incisions  into  this  space,  the  knife  should 
be  entered  at  the  centre  of  the  floor  of  the  axilla, 
i.e.  midway  between  the  anterior  and  posterior 
margins,  and  near  to  the  inner  or  thoracic  side 
of  the  space.  The  vessels  most  likely  to  be  damaged 
by  an  indiscreet  incision  are  the  subscapular, 
running  along  the  lower  border  of  the  subscapu- 
laris muscle;  the  lateral  (long)  thoracic,  follow- 
ing the  lower  border  of  the  small  pectoral;  and 
the  main  vessels  lying  close  to  the  humerus. 
The  knife,  if  properly  entered,  should  be  mid- 
way between  the  two  first-named  vessels,  and 
quite  away  from  the  main  trunks.  There  is  an 
artery  that  sometimes  comes  off  as  the  lowest 
branch  of  the  axillary  trunk,  and  crosses  the 
middle  of  the  axilla,  to  be  distributed  to  the 
thorax  below  the  long  thoracic.  This  vessel  would 
probably  be  wounded  in  the  incision  above  named. 
The  artery  is,  however,  very  inconstant,  is  small, 
and  is  not  far  below  the  surface.  It  is  usually 
met  with  in  female  subjects. 

Lymphatic  glands  of  the  axilla.— The  axillary 
glands  are  numerous,  and  of  much  surgical  im- 
portance (see  Fig.  53,  p.  222).  They  may  be 
arranged  in  four  sets.  (1)  The  greater  number 
are  placed  to  the  inner  side  of  the  axillary  vein 
beneath  the  axillary  tuft  of  hair.  This  central 
set  of  glands  receives  the  lymph  from  the  upper 
extremity  and  breast.  Pain  in  the  axilla  which 
follows  whitlow  or  any  septic  infection  of  the  arm 


250  THE    UPPER    EXTREMITY  [CHAP. 

is  due  to  inflammation  of  this  group,  which  is 
pierced  by  the  intercosto-humeral  nerve.  (2)  The 
deep  axillary  set  lies  along  the  axillary  vessels.  It 
receives  the  lymph  from  the  central  set  and  becomes 
continuous  with  the  lower  deep  cervical  glands 
in  the  subclavian  triangle.  (3)  Other  glands  lie 
upon  the  serratus  magnus  muscle  on  the  thoracic 
side  of  the  axilla,  and  just  behind  the  lower 
border  of  the  pectoral  muscles.  They  receive  the 
lymphatics  from  the  front  of  the  chest,  the  princi- 
pal lymjDh-vessels  of  the  breast,  and  the  superficial 
lymphatics  of  the  abdomen  as  low  down  as  the 
umbilicus.  Their  efferent  vessels  for  the  most  part 
pass  on  to  join  the  central  set  of  glands.  These 
glands  will  be  the  first  to  be  enlarged  in  certain 
breast  affections,  and  after  blistering  and  other 
superficial  inflammations,  etc.,  of  the  chest  and 
upper  abdomen.  The  axillary  process  of  the 
female  breast  is  in  contact  with  this  set.  (4)  The 
remaining  glands  are  situated  at  the  back  of 
the  axilla,  along  the  subscapular  vessels.  They  are 
joined  by  the  lymphatics  from  the  scapular  and 
lumbar  regions  of  the  back. 

It  may  here  be  convenient  to  note  that  one  or 
two  glands  are  commonly  found  in  the  groove 
between  the  deltoid  and  pectoralis  major  muscles. 
They  receive  some  vessels  from  the  outer  side  of 
the  arm  and  a  part  of  the  shoulder  and  breast. 
The  superficial  lymphatics  over  the  upper  part  of 
the  deltoid  go  to  the  cervical  glands  (Tillaux), 
over  the  lower  half  to  the  axilla.  The  lymphatics 
from  the  supraspinous  fossa  follow  the  supra- 
scapular  (transverse  scapular)  artery,  and  join  the 
lowest  cervical  glands.  The  superficial  lymphatics 
of  the  back  which  converge  to  the  axilla  are 
derived  from  the  neck  over  the  trapezius  muscle, 
and  from  the  whole  dorsal  and  lumbar  regions 
as  far  down  as  the  iliac  crest. 

The  complete  removal  of  axillary  glands  is 
an  operation  frequently  undertaken,  especially  in 
cases  of  mammary  cancer.  Free  access  to  them 
is  obtained  by  reflecting  the  pectoral  muscles 


xi]  VESSELS    OF   THE   AXILLA  257 

inwards.  It  will  be  understood  from  their  posi- 
tion that  these  bodies,  when  diseased,  are  very 
apt  to  become  adherent  to  the  axillary  vessels, 
and  especially  to  the  vein.  The  latter  vessel  has 
frequently  been  wounded  or  excised  during  the 
removal  of  gland  tumours,  and  one  case  at 
least  is  recorded  in  which  the  artery  was  acci- 
dentally cut  (Holmes). 

Axillary  vessels. — The  axillary  vein  is  formed 
by  the  union  of  the  basilic  with  the  two  venae 
comites  of  the  brachial  artery.  This  union  com- 
monly takes  place  at  the  lower  border  of  the 
pectoralis  minor  muscle,  and  the  vein  is  therefore 
shorter  than  the  artery.  Sometimes  the  vein  does 
not  exist  as  a  single  trunk  until  just  below  the 
clavicle.  This  condition,  when  present,  is  very 
unfavourable  to  operations  upon  the  artery,  as 
many  transverse  branches  cross  that  vessel  to  unite 
the  veins  that  lie  on  either  side  of  it.  The  axil- 
lary vein,  being  comparatively  near  the  heart,  is 
readily  influenced  as  regards  its  contained  blood 
by  the  inspiratory  movement.  Thus  it  happens 
that,  in  many  instances  of  wound  of  the  vessel  or 
of  its  larger  tributaries,  air  has  been  drawn  into 
the  venous  canal  and  death  has  ensued.  The  en- 
trance of  air  into  the  main  vein  is  perhaps  aided 
by  the  circumstance  that  the  costo-coracoid  mem- 
brane (upper  part  of  the  clavi-pectoral  fascia)  is 
adherent  to  the  vessel,  and  thus  tends  to  maintain 
it  in  a  patent  condition  when  wounded.  This 
connexion  with  the  fascia  is  supposed  by  some  to 
account  in  part  for  the  furious  bleeding  that 
occurs  from  this  vein  when  it  is  divided. 

The  vein  is  more  often  wounded  than  is  the 
artery,  it  being  larger,  more  superficial,  and  so 
placed  as  more  or  less  to  ^  overlap  the  arterial 
trunk.  On  the  other  hand,  in  injury  to  the  vessel 
by  traction,  as,  for  example,  in  reducing  disloca- 
tions, the  artery  suffers  more  frequently  than  the 
vein.  In  all  positions  of  the  upper  limb  the 
artery  keeps  to  the  outer  angle  of  the  axillary 
space.  The  relation  of  the  vein,  however,  to  the 
j 


258  THE    UPPER    EXTREMITY  [CHAP. 

first  part  of  the  axillary  artery,  the  part  above 
the  pectoralis  minor,  is  modified  by  the  position 
of  the  limb.  Thus,  when  the  arm  hangs  by  the 
side  the  vein  is  to  the  inner  medial  side  of  the 
artery,  and  a  little  in  front  of  it,  but  when 
the  limb  is  at  a  right  angle  with  the  trunk  the 
vein  is  drawn  so  far  in  front  of  the  artery  as 
almost  entirely  to  conceal  that  vessel. 

Aneurysm  is  very  frequent  in  the  axillary 
artery,  a  fact  to  be  explained  by  the  nearness  of 
the  vessel  to  the  heart^by  the  abrupt  curve  it  pre- 
sents, by  its  susceptibility  to  frequent  and  exten- 
sive movements,  and  by  its  liability  to  share  in  the 
many  lesions  of  the  upper  limb.  In  violent  and 
extreme  movements  of  the  limb  the  artery  may  be 
more  or  less  torn,  especially  if  its  walls  are 
already  diseased. 

In  ligaturing  the  first  part  of  the  axillary 
artery  it  is  well  to  note  that  the  pectoralis  major 
has  sometimes  a  cellular  interval  between  two 
planes  of  muscle  fibre,  and  this  may  be  mistaken 
for  the  space  beneath  it  (Heath).  If  the  pector- 
alis minor  has  an  origin  from  the  second  rib,  it 
may  more  or  less  entirely  cover  the  artery  and  re- 
quire division.  The  cord  of  the  brachial  plexus 
nearest  to  the  artery  may^  be  mistaken  for  that 
vessel,  or  easily  included  in  a  ligature  intended 
for  it.  A  ready  guide  to  the  axillary  vessels  in 
this  operation  is  to  follow  the  cephalic  vein.  The 
anterior  internal  thoracic  nerve  appears  between 
the  vein  and  artery  as  it  passes  to  the  pectoralis 
minor;  it  also  may  be  useful  occasionally  as  a 
guide. 

In  applying  a  ligature  to  the  third  part  of  the 
artery,  it  should  be  borne  in  mind  that  a  mus- 
cular slip  sometimes  crosses  the  vessels  obliquely, 
passing  from  the  latissimus  dorsi  to  join  the  pec- 
toralis major,  coraco:brachialis,  or  biceps  mus- 
cles. This  slip  may  give  rise  to  confusion  during 
the  operation,  and  may  'be  mistaken  for  the 
coraco-brachialis. 

Brachial  plexus.— When  the  shoulder  is  depressed 


xi]  BRACHIAL  PLEXUS  259 

the  upper  and  middle  trunks  of  the  brachial 
plexus,  formed  by  the  fifth,  sixth,  and  seventh 
cervical  nerves,  can  be  distinctly  felt  in  the  neck, 
passing  from  beneath  the  posterior  border  of 
the  sterno-mastoid  to  enter  the  axilla  just  ex- 
ternally to  the  mid-point  of  the  clavicle  (Fig.  58). 
As  the  trunks  of  the  plexus  pass  towards  the 
upper  surface  of  the  first  rib,  where  they  lie 
above  and  dorsally  to  the  subclavian  artery,  the 
nerve-trunks  are  surrounded  by  a  lax  connective 
tissue,  permitting  free  movements  of  the  plexus 
as  the  shoulder  is  elevated  and  depressed.  It  is 
at  this  part  of  the  supraclavicular  region  where 
the  nerve-cords  can  be  felt  above  and  behind  the 
pulsations  of  the  artery,  particularly  when  the 
patient  is  sitting  up  with  the  shoulder  depressed, 
that  injections  are  made  into  the  plexus  to  produce 
ancesthesia  in  the  arm. 

The  upper  trunk,  formed  by  the  fifth  and 
sixth  nerves,  is  by  far  the  most  exposed  to 
injury,  for  the  reason  that  it  rises  higher  in 
the  neck  than  the  middle  and  lower  trunks; 
consequently,  if  the  neck  is  bent  forcibly  to  the 
left,  as  when  a  burden  is  borne  on  the  <  right 
shoulder,  the  upper  trunk  on  the  right  side  is 
subjected  to  a  greater  strain  than  the  middle 
or  lower  cords  (Fig.  59).  In  cases  of  shoulder- 
presentation  at  birth,  or  if  the  neck  and  shoulder 
be  forced  apart  by  accident,  the  upper  cord  is 
liable  to  be  strained  or  ruptured,  resulting  in 
what  is  usually  described  as  Erb's  palsy.  It  will 
be  recalled  that  the  suprascapular,  circumflex 
(axillary),  and  musculo-cutaneous  nerves  are  de- 
rived from  this  trunk;  so  are  the  nerves  to  the 
rhomboids  and  serratus  magnus.  The  rupture, 
however,  is  usually  distal  to  the  origin  of  these 
nerves,  and  hence  their  muscles  escape.  The  muscles 
affected  in  Erb's  palsy  are  thesupraspinatus,  infra- 
spinatus,  teres  minor,  deltoid,  coraco-brachialis, 
biceps,  brachialis,  and  brachio-radialis ;  occasion; 
ally  also  the  supinator  (brevis),  extensor  carpi 
radialis  longior,  and  pronator  (radii)  teres.  No 


260 


THE    UPPER    EXTREMITY 


[CHAP. 


sensory  paralysis  is  observed  in  such  cases.  Curi- 
ously enough,  section  of  the  fifth  cervical  gives 
as  wide  an  area  of  muscular  paralysis  as  section 
of  the  combined  fifth  and  sixth  (Wilfred  Harris). 
In  complete  rupture  of  the  brachial  plexus,  sensa- 
tion is  completely  lost  beyond  the  elbow,  but  in 
the  arm  and  shoulder  deep  sensibility  is  retained 
(Sherren).  The  arm,  in  such  lesions,  retains  intact 


3  C. 


Ml/SCs-SflRAL 
POST.  CIRCUMFLEX 


Fig.  59. — Upper  and  middle  trunks  of  the  brachial  plexus 
viewed  from  behind  to  show  how  depression  of 
the  shoulder  or  lateral  abduction  of  the  head  may 
produce  stretching  and  injury  of  the  nerve-cords. 

{After  Poiricr.) 

the  nerves  received  from  the  descending  cervical 
and  intercosto-humeral. 

Axillary  nerves. — Any  of  the  axillary  nerves 
may  be  injured  by  a  wound,  the  median  being 
the  most  frequently  damaged,  and  the  musculo- 
spiral  ^the  least  frequently.  The  comparative 
immunity^  of  the  latter  is  explained  by  its  deep 
position,  its  situation  at  the  inner  and  posterior 


XI] 


DELTOID   REGION 


261 


aspect  of  the  limb,  and  its  large  size.  The  nerves 
are  very  seldom  torn  by  a  traction  on  the  limb 
short  of  more  or  less  complete  avulsion.  Indeed, 
if  forcibly  stretched,  they  are  disposed  rather  to 
become  torn  away  from  their  attachments  to  the 
spinal  cord  than  to  give  way  in  the  axilla.  Thus, 
Flaubert  records  a  case  where  the  last  four  cervi- 
cal nerves  were  torn  away  from  the  cord  during 
a  violent  attempt  to  reduce  a  dislocated  shoulder. 


•  UPRASPINATUS 


SCAPULA 


1-  CAPSULE 

__/POST.ClR.CU/MFLE:X  AR.T 


Fig.  60.—  Section  of  shoulder-joint  to  show  the  relations  of 
the  capsule,  epiphyseal  line,  and  bursa.     (After  Poirier.} 

The  deltoid  region.  —  This  region,  comprising 
as  it  does  the  "  point  "  of  the  shoulder,  is  limited 
in  all  parts  by  the  deltoid  muscle.  The  deltoid 
covers  the  upper  end  of  the  humerus  and  the 
shoulder-joint  (Fig.  60).  Between  the  joint  and 
the  surface,  therefore,  are  only  the  skin  and  super- 
ficial fascia,  the  deltoid  in  its  sheath,  and  some 
loose  connective  tissue  (the'  subdeltoid  tissue)  in 
which  is  found  the  great  subdeltoid  (subacromial) 


262  THE    UPPER    EXTREMITY  [CHAP. 

bursa.  This  subdeltoid  tissue  sometimes  assumes 
the  form  of  a  distinct  thick  membrane,  and  may 
have  an  important  influence  upon  the  localization 
of  purulent  collections  proceeding  from  the  joint. 
The  fatty  tissue  over  the  deltoid  is  a  favourite 
seat  for  lipomata,  and  it  is  in  this  situation 
that  the  tendency  of  these  growths  to  change  their 
position  is  sometimes  seen.  Thus,  Erichsen  records 
a  case  where  the  tumour  slid  downwards  from 
the  shoulder  to  the  breast. 

Emerging  from  the  interval  between  the  two 
teres  muscles,  and  winding  horizontally  round  the 
shaft  of  the  humerus,  quite  close  to  the  bone,  and 
about  the  line  of  the  surgical  neck,  are  the  circum- 
flex nerve  and  posterior  circumflex  artery  (Fig.  58, 
p.  253,  and  Fig.  85,  p.  392).  This  nerve  affords 
an  example  of  an  arrangement  pointed  out  by 
Hilton,  viz.  that  a  principal  nerve  to  a  joint 
not  only  supplies  the  articular  surfaces,  but  also 
some  of  the  main  muscles  that  move  that  joint, 
and  the  skin  over  those  muscles.  This  nerve 
supplies  the  shoulder-joint,  the  deltoid  and  teres 
minor  muscles,  and  the  skin  over  the  lower 
two-thirds  of  the  shoulder  and  upper  part  of 
the  triceps.  It  is  frequently  damaged  in  injuries 
to  the  shoulder,  and  may  be  severely  bruised 
by  a  simple  contusion  of  the  part,  resulting 
in  paralysis  of  the  deltoid.  It  would  appear, 
however,  that  damage  to  the  circumflex  is  much 
less  frequent  after  contusions  of  the  shoulder 
than  was  formerly  maintained.  It  will  also  be 
readily  understood  that  the  nerve  is  often  torn 
in  fractures  of  the  surgical  neck  of  the  humerus, 
in  dislocations  of  that  bone  (especially  the  luxa- 
tion backwards),  and  in  violent  attempts  at 
reducing  such  dislocations  (Figs.  58  and  59). 

The  shoulder-joint. — From  one  surgical  point 
of  view,  joints  may  be  divided  into  (1)  those  that 
depend  -for  their  strength  mainly  upon  ligaments ; 
(2)  those  that  are  mechanically  strong,  and  that 
derive  their  stability  to  a  great  extent  from  the 
arrangement  of  their  component  bones;  and  (3) 


XT]  THE  SHOULDER- JOINT  263 

those  that  rely  for  their  support  principally  upon 
muscles.  As  an  example  of  the  first  kind  may  be 
cited  the  sterno-clavicular  joint,  of  the  second 
form  the  elbow- joint,  and  of  the  third  the 
shoulder- joint.  m  The  articulation  the  least  prone 
to  dislocation  is  the  one  that  derives  its  strength 
from  tough  unyielding  ligaments,  while  the  one 
most  often  luxated  belongs  to  the  third  variety,  its 
strength  being  greatly  dependent  upon  muscles 
that  may  be  taken  by  surprise,  and  that  may  them- 
selves, from  disordered  action,  prove  sources  of 
weakness.  These  are,  of  course,  not  the  only  fea- 
tures in  the  etiology  of  dislocation.  A  great  deal 
depends  upon  the  amount  of  movement  permitted 
in  a  given  joint,  and  the  degree  of  leverage  that 
can  be  brought  to  bear  upon  its  parts. 

The  arch  formed  by  the  coracoid  and  acromion 
processes  and  the  ligament  between  them  forms  an 
essential  support  to  the  head  of  the  humerus,  and 
is  an  important  constituent  of  the  articulation. 
With  this  arch  the  humeral  head  is  in  immediate 
relation,  though  not  in  actual  contact  (Fig.  60). 
In  paralysis  of  the  deltoid  the  head  may  be 
separated  by  some  distance  from  the  coracoid 
process,  and  Nannoni  records  the  case  of  a  child 
with  old-standing  paralysis  of  the  deltoid  between 
whose  humeral  head  and  acromial  vault  four  fin- 
gers could  be  lodged.  It  is  well  to  note  that  at 
least  two-thirds  of  the  head  of  the  bone  are  not 
in  contact  with  the  glenoid  cavity  when  the  arm 
hangs  by  the  side,  and  Anger  points  out  that  in 
this  position  three-fourths  of  the  circumference 
of  the  humeral  head  are  in  front  of  a  vertical  line 
drawn  from  the  anterior  border  of  the  acromion 
process.  In  this  posture,  also,  the  head  is  wholly 
to  the  outer  side  of  the  coracoid  process.  The 
margin  of  the  glenoid  cavity  is  more  prominent 
on  the  inner  than  on  the  outer  side,  while  the 
strongest  part  of  the  margin  and  the  broadest 
part  of  the  fossa  are  below.  This  is  significant, 
since  it  points  to  an  attempt  to  strengthen  a  part 
of  the  joint  that  practice  shows  to  be  the  weakest 


264  THE    UPPER    EXTREMITY  [CHAP. 

in  the  articulation,  viz.  the  lower  and  inner  por- 
tion of  the  capsule.  It  is  at  this  place  that  the 
head  of  the  bone  leaves  the  joint  in  dislocation  of 
the  shoulder. 

The  capsule  of  the  shoulder- joint  is  very  lax, 
and  would  lodge  a  bone-head  twice  as  large  as  that 
of  the  humerus.  According  to  Sir  Henry  Morris, 
no  one  part  of  the  capsule  is  constantly  thicker 
than  the  rest,  as  is  the  case  in  the  hip-joint. 

Of  the  bursae  about  the  joint,  the  subacromial 
bursa  is  the  one  most  frequently  the  seat  of  disease. 
This  sac,  when  distended  with  fluid,  may  be  mis- 
taken for  the  results  of  chronic  inflammation  of 
the  joint  (Fig.  60). 

Experiment  shows  that  the  walls  of  this  bursa 
may  be  actually  torn  in  twists  of  the  arm,  espe- 
cially when  either  flexed  or  extended.  When 
the  sac  is  distended,  most  pain  is  elicited  in 
the  position  of  abduction,  for  in  this  posture  the 
bursal  walls  are  normally  folded  up,  so  as  to 
form  a  sort  of  collar  in  advance  of  the  greater 
tuberosity.  In  elderly  rheumatic  people  the  sac 
sometimes  communicates  with  the  joint.  The  sub- 
scapular  bursa  may  be  regarded  as  an  extension 
of  the  synovial  membrane  of  the  joint  between 
the  terminal  part  of  the  muscle  and  the  scapula. 
Pain  elicited  when  the  arm  is  rotated  at  the 
shoulder-joint  may  be  due  to  disease  in  the  joint, 
or  in  the  subacromial  or  the  subscapular  bursa, 
for  a  movement  then  occurs  in  all  three. 

The  biceps  tendon  strengthens  the  upper  part 
of  the  joint,  keeps  the  humerus  against  the  glen- 
oid  cavity  in  the  various  positions  of  the  limb, 
and  prevents  the  head  of  the  bone  from  being 
pulled  too  closely  upwards  under  the  acromion. 
The  tendon  may  be  ruptured,  and  in  such  a  case, 
in  addition  to  the  general  weakening  of  the  limb, 
and  the  peculiar  projection  formed  by  the  con- 
traction of  the  muscle,  the  head  of  the  humerus  is 
usually  drawn  upwards  and  forwards  until  ar- 
rested by  the  coraco-acromial  arch.  Thus,  a  kind 
of  slight  false  dislocation  may  be  produced.  In 


xi]  DISEASE   OF   SHOULDER-JOINT         265 

certain  violent  wrenches  of  the  limb  the  tendon 
may  rupture  the  transverse  ligament  which  binds 
it  down,  slip  from  its  groove,  and  be  displaced 
to  one  or  other  side,  usually  to  the  inner  side. 
The  intracapsular  part  of  the  tendon  may  ^dis- 
appear  in  cases  of  chronic  rheumatic  arthritis, 
owing  to  the  friction  against  the  abraded  arti- 
cular surface  of  the  .humerus.  In  such  cases  it 
acquires  an  attachment  to  the  bicipital  groove. 

Disease  of  the  shoulder=joint. — This  articulation 
is  liable  to  all  forms  of  joint-disease.  The  capsule, 
as  just  stated,  is  very  lax,  the  articular  surfaces 
being  kept  in  apposition  by  the  tonus  of  the  sur- 
rounding muscles ;  when  chloroform  is  administered 
the  surfaces  may  be  freely  separated  and  examined. 
In  joint-disease,  however,  the  effusion  may  effect  a 
considerable  separation  of  the  two  bones.  Braune, 
having  pierced  the  glerioid  cavity  through  the 
supraspinpus  fossa,  injected  tallow  at  considerable 
pressure  into  the  joint.  When  fully  distended 
the  humerus  was  found  to  be  separated  from  the 
scapula  by  more  than  \  an  inch,  and  this  may 
serve  to  explain  the  lengthening  of  the  limb  often 
noted  in  joint-disease  of  this  part  with  much 
effusion.  When  the  greatest  degree  of  distension 
of  the  capsule  was  reached  the  humerus  became 
slightly  extended  and  rotated  inwards.  It  is 
significant  that  in  shoulder-joint  disease  it  is  com- 
mon for  the  arm  to  be  found  close  to  the  side,  the 
elbow  carried  a  little  back  (extension),  and  the 
limb  rotated  inwards.  This  position  may  also  be 
due  to  the  rigid  contraction  of  the  muscles  about 
the  joint.  When  such  contractions  exist  it  may 
be  inferred  that  the  powerful  latissimus  dorsi 
has  a  little  advantage  over  its  opponents,  and 
may  be  answerable  for  the  rotation  in  and  slight 
projection  ^backwards  of  the  arm.  The  inner  part 
of  the  epiphyseal  line  is  just  within  the  cap- 
sule; the  outer,  anterior  and  posterior  parts 
are  entirely  subperiosteal.  It  happens,  therefore, 
that  the  jpus  in  suppurative  epiphysitis  will  find 
its  way  into  the  joint. 


266  THE    UPPER    EXTREMITY  [CHAP 

There  are  two  diverticula  from  the  synovial 
membrane  :  (1)  one  that  runs  some  way  down  the 
bicipital  groove  (intertubercular  sulcus)  with  the 
tendon;  (2)  a  cul-de-sac  beneath  the  subscapu- 
laris  formed  by  a  communication  between  the 
synovial  cavity  and  the  bursa  under  that  muscle. 
When  the  joint  is  filled  with  effusion  the  cap- 
sule is  evenly  distended  and  the  shoulder  evenly 
rounded.  Special  projections  usually  occur  at 
the  seats  of  the  diverticula.  Thus  a  swelling 
often  appears  early  in  the  course  of  a  synovitis 
in  the  groove  between  the  pectoralis  major  and 
the  deltoid  muscles,  and  this  swelling  may  ap- 
pear bilobed,  being  cut  in  two  by  the  unyielding 
biceps  tendon.  Fluctuation  can  best  be  felt  by 
examining  the  uncovered  part  of  the  capsule  in 
the  axilla  beyond  the  subscapular  muscle.  When 
the  joint  suppurates,  pus  usually  escapes  at  one 
of  the  culs-de-sac  just  mentioned,  most  often 
through  the  one  that  follows  the  biceps  tendon. 
Pus  may  thus  extend  for  some  way  along  the 
bicipital  groove.  In  one  recorded  case,  pus  that 
had  escaped  from  the  shoulder-joint  followed  the 
course  of  the  musculo-spiral  (radial)  nerve,  and 
opened  on  the  outer  side  of  the  elbow. 

Dislocations.— Dislocations  at  this  joint  are 
more  common  than  at  any  other  joint  in  the  body. 
This  is  explained  by  the  shallowness  of  the  glenoid 
fossa,  the  large  size  and  globular  shape  of  the  head 
of  the  humerus,  the  extensive  movements  of  the 
arm,  the  long  leverage  it  affords,  and  the  depend- 
ence of  the  articulation  for  its  strength  mainly 
upon  muscles.  The  upper  limb  and  shoulder  are 
also  peculiarly  exposed  to  injury. 

The  principal  forms  of  luxation  of  the  humerus 
at  the  shoulder  are  :  1  Subcoracoid,  forwards  and 
a  little  downwards;  the  usual  form.  2.  Sub- 
fjlenoid,  downwards  and  a  little  forwards;  rare. 
3.  Subspinous,  backwards;  rare. 

In  all  complete  dislocations  the  head  of  the 
bone  leaves  the  joint-cavity  through  a  rent  in 
the  capsule.  In  so-called  "false  luxations"  the 


xi]      DISLOCATIONS   OF  SHOULDER-JOINT     267 

capsule  is  not  torn.  For  example,  in  the  cadaver, 
if  the  deltoid  be  divided  the  humeral  head  can 
be  displaced  under  the  coracoid  process  without 
rupture  of  the  capsule;  and  the  same  thing  may 
occur  during  life,  in  cases  where  the  muscle  has 
long  been  paralysed. 

In  all  cases  of  dislocation  at  this  joint  the 
primary  displacement  is  always  downwards  into 
the  axilla.  It  is  well  known  that  dislocations  at 
the  shoulder  are  usually  due  to  violence  applied 
to  the  limb  while  the  arm  is  abducted,  or  to  severe 
direct  violence  forcing  the  bone  downwards.  Now, 
when  the  limb  is  abducted  the  head  of  the  humerus 
projects  below  the  glenoid  fossa,  and  rests  and 
presses  upon  the  inferior  and  least  protected  part 
of  the  capsule.  The  fibres  of  this  portion  of  the 
capsule  being  tightly  stretched  in  this  position, 
it  requires  the  exertion  of  no  extraordinary  force 
to  tear  the  ligament  and  drive  the  bone  into 
the  axilla. 

Thus  it  happens  that  in  luxations  at  this  joint 
the  rent  in  the  capsule  is  at  its  inferior  and  inner 
aspect,  the  humeral  head  lying  beneath  the  sub- 
scapularis,  which  is  always  strained  and  some- 
times torn.  The  head  of  the  bone,  being  thus 
driven  downwards  into  the  axilla,  may,  for  cer- 
tain reasons,  remain  there  (subglenoid  form),  or 
more  usually  it  will  be  drawn  forwards  and  in- 
wards by  the  powerful  pectoralis  major,  aided 
by  other  muscles  whose  action  is  now  less  resisted 
and  by  the  weight  of  the  unsupported  limb  (sub- 
coracoid  form);  and  lastly,  the  direction  of  the 
violence  being  applied  markedly  from  in  front, 
the  head  of  the  bone  may  be  thrust  backwards 
under  the  acromion  or  spinous  processes  (sub- 
spinous  form).  The  overwhelming  frequency  of 
the  subcoracoid  variety  is  explained  by  the  greater 
advantage  at  which  those  muscles  act  that  draw 
the  bone  forwards,  in  comparison  with  those  that 
would  draw  it  backwards,  and  by  the  very  trifling 
opposition  offered  to  the  passage  of  the  head 
forwards  when  compared  with  the  substantial 


268  THE    UPPER    EXTREMITY  [CHAP. 

obstacles   in   the   way    of   its   passage   backwards 
under  the  scapular  spine. 

Features  common  to  all  dislocations  at  the 
shoulder. — As  the  roundness  of  the  deltoid  depends 
to  a  great  extent  upon  the  presence  beneath 
it  of  the  humeral  head,  and  as  in  all  these 
luxations  (save  perhaps  in  the  slighter  grades  of 
the  subspinous  form)  the  head  is  removed  practi- 
cally from  its  connexion  with  the  deltoid,  that 
muscle  is  always  more  or  less  flattened.  This 
flattening  is  augmented  by  the  stretching  of  the 
muscle  which  in  some  degree  is  constantly  present. 
Stretching  of  the  deltoid  involves  abduction  of 
the  arm,  and  this  symptom  is  fairly  constant 
in  all  the  luxations.  The  biceps  being  also  more 
or  less  unduly  tense,  the  elbow  is  found  flexed 
and  the  forearm  supinated.  In  every  form  there 
is  some  increase  in  the  vertical  circumference 
of  the  axilla,  since  the  head,  having  left  the 
glenoid  fossa,  must  occupy  some  part  comprised 
within  that  circumference.  Again,  Dr.  Dugas 
has  pointed  out  that  "  if  the  fingers  of  the  in- 
jured limb  can  be  placed  by  the  patient,  or  by  the 
surgeon,  upon  the  sound  shoulder  while  the  elbow 
touches  the  thorax  (a  condition  that  obtains  in 
the  normal  condition  of  the  joint),  there  can  be 
no  dislocation  ;  and  if  this  cannot  be  done  there 
must  be  one,  for  no  injury  other  than  a  disloca- 
tion can  induce  this  physical  impossibility."  This 
depends  upon  the  fact  that  in  consequence  of  the 
rotundity  of  the  thorax  it  is  impossible  for  both 
ends  of  the  humerus  to  touch  it  at  the  same  time, 
and  in  luxation  at  the  shoulder  the  upper  end  of 
the  bone  is  practically  touching  the  trunk.  Lastly, 
from  the  position  of  the  great  vessels  and  nerves 
(Fig.  58)  it  will  be  seen  that  in  the  subcoracoid 
and  subglenoid  luxations  the  head  of  the  bone 
may  press  injuriously  upon  those  structures. 
Thus  may  result  O3dema  of  the  limb  and  severe 
pain  or  loss  of  muscular  power.  ^  The  artery  is 
usually  saved  by  its  greater  elasticity ;  but  Berard 
reports  a  case  of  displacement  forwards  where 


XI] 


SUBCORACOID   DISLOCATION 


269 


the  axillary  artery  was  so  compressed  by  the 
humeral  head  as  ;to  induce  gangrene  of  the  limb. 
The  close  connexion  of  the  circumflex  nerve  with 
the  humerus  renders  it  very  liable  to  injury, 
especially  in  the  subglenoid  and  subspinous  forms 
of  dislocation. 

Special  anatomy  of  each  form  of  shoulder  dis= 
location.  1.  Subcoracoid. — The  articular  head  of 
the  humerus  lies 
on  the  anterior 
surface  of  the  neck 
of  the  scapula, 
and  the  anatomi- 
cal neck  rests  on 
the  anterior  lip 
of  the  g  1  e  n  o  i  d 
fossa.  The  head  is 
thus  placed  imme- 
diately below  the 
coracoid  process, 
and  is  in  front  of, 
internal  to,  and 
a  little  below  its 
normal  site.  The 
great  tuberosity 
faces  the  emj)ty 
g  1  e  n  o  i  d  cavity 
(Fig.  61).  Thesub- 
scapularis  muscle 

is  stretched  over  Fig.  61.— Subcoracoid  dislocation 
the  head  of  the  of  the  humerus. 

humerus,    and     is 

usually  partly  torn.  The  supraspinatus,  infra- 
spinatus,  and  teres  minor  are  stretched  or  torn, 
or  the  great  tuberosity  may  even  be  wrenched 
off.  The  coraco-brachialis  and  short  head  of  the 
biceps  are  tense,  and  are  immediately  in  front 
of  the  head  of  the  humerus  instead  of  to  its 
inner  side.  The  long  tendon  of  the  biceps  is 
deflected  downwards  and  outwards.  It  is  some- 
times, although  rarely,  torn  from  its  groove.  The 
deltoid  is  put  upon  the  stretch.  The  prominence 


270  THE    UPPER    EXTREMITY  [CHAP. 

formed  by  the  humeral  head  in  the  front  of  the 
axilla  depends  to  some  degree  upon  the  amount 
of  rotation.  If  the  bone  be  rotated  out,  the 
projection  is  most  distinct;  but  if  rotated  in, 
its  head  sinks  into  the  axilla  and  is  brought 
more  in  contact  with  the  scapula  than  with  the 
skin.  The  head  of  the  bone  being  always  carried 
a  little  downwards,  some  lengthening  must  in  all 
cases  really  exist;  but  with  the  ordinary  method 
of  measuring  the  limb  this  lengthening  may  be 
replaced  by  a  normal  measurement,  or  even  by 
apparent  shortening,  if  the  head  of  the  bone  be 
carried  a  good  deal  forwards  and  inwards,  and 
the  limb  be  abducted.  When  the  head  has  left 
the  glenoid  cavity,  abduction  tends  to  bring  the 
external  (lateral)  condyle  nearer  to  the  acromion, 
and  these  are  the  two  points  between  which  the 
measurement  is  usually  taken.  Thus  the  apparent 
length  of  the  arm  depends  mainly  upon  the  degree 
of  abduction  of  the  humerus,  or  the  obliquity  of 
the  axis  of  the  bone. 

2.  Subglenoid. — The  head  is  below,  and  a  little 
in  front  of  and  internal  to,  its  normal  position. 
It  cannot  go  directly  downwards,  owing  to  the 
situation   of   the   long   head   of   the   triceps,    but 
escapes  in  the  interval  between  that  muscle  and 
the  subscapularis.     The  articular  surface  of  the 
head  rests  on  the  anterior  aspect  of  the  triangular 
area  just  below  the  glenoid  fossa  that  gives  origin 
to  the   triceps.^    The  upper   border   of  the  great 
tuberpsity    is    in    close    relation    with   the    lower 
margin  of  the  joint.     The  subscapularis  muscle, 
which   binds    down    the    humeral    head,    is   much 
stretched   or   torn.      The   supraspinatus    and   the 
infraspinatus  are  stretched  or  torn,  and  the  two 
teres  muscles  have  not  been  much  affected  unless 
there  be  considerable  abduction  of  the  arm.     The 
coraco-brachialis    and   biceps    are   stretched,    and 
owing  to  the  amount  of  abduction  usually  present, 
the  biceps  tendon   is  but  little  deflected   from   a 
straight  line. 

3.  Subspinous. — The  head  usually  rests  on  the 


XI] 


SUBSPINOUS    DISLOCATION 


271 


posterior  surface  of  the  neck  of  the  scapula,  the 
groove  of  the  anatomical  neck  of  the  humerus 
corresponding  to  the  posterior  lip  of  the  glenoid 
fossa.  The  head  is  thus  placed  beneath  the 
acromion ;  but  it  may  be  displaced  still  farther 
back,  and  may  rest  on  the  dorsum  scapulae,  and 
beneath  the  scapular  spine  (Fig.  62).  The  sub- 
scapular  is  tendon  is  drawn  right  across  the 
glenoid  fossa,  and  is  often  torn  from  its  attach- 
ment. The  head  pushes 
back  the  hinder  part  CT 
of  the  deltoid,  the  in-  \ 
fraspinatous  and  teres 
minor  muscles.  These 
latter  cover  the  bone, 
and  are  stretched  over 
it.  The  great  pectoral 
is  rendered  unduly 
tense,  and  this  serves 
in  part  to  explain 
the  rotation  inwards 
of  the  humerus, 
and  the  abduction 
forwards,  which  are 
usually  observed,  those 
movements  being  more 
or  less  unopposed.  The 
circumflex  nerve  is 
often  torn. 

In    reducing   dislo- 
cations, and  especially 

such  as  are  of  long  standing,  serious  damage 
may  be  inflicted  on  the  axillary  structures.  The 
axillary  artery  suffers  most  frequently,  the  vein 
rarely,  and  the  nerves  still  less  often.  The  artery, 
being  placed  externally,  is  apt  to  contract  ad- 
hesions to  the  soft  parts  covering  the  head  of 
the  displaced  bone,  and  therefore  to  be  torn  when 
those  parts  are  disturbed  (Fig.  58). 

Fractures  of  the  upper  end  of  the  humerus. 
1.  Anatomical  neck.  —  The  upper  part  of  the 
capsule  is  exactly  attached  to  the  anatomical 


Fig.  62.— Subspinous  disloca- 
tion of  the  humerus. 


272  THE    UPPER    EXTREMITY  [CHAP. 

neck,  and  in  this  situation  the  fracture  may  run 
beyond  the  ligament  and  be  partly  extracapsular 
(Fig.  60,  p.  261).  The  lower  part  of  the  capsule 
is  inserted  some  little  way  below  the  anatomi- 
cal neck,  and  in  this  position,  therefore,  the 
lesion  must  be  intracapsular.  From  the  lino  of 
attachment  of  the  lower  part  of  the  capsule  to 
the  humerus,  fibres  are  reflected  upwards  to  the 
margin  of  the  articular  cartilage  on<  the  head  of 
the  bone.  These  fibres,  if  unruptured,  may  serve 
to  connect  the  fragments.  It  is  easy  for  the 
small  and  comparatively  dense  upper  fragment 
to  be  driven  into  the  wide  extent  of  cancellous 
bone  exposed  on  the  upper  surface  of  the  lower 
fragment.  When  impaction  occurs,  there  may  be 
some  flattening  of  the  deltoid,  since  the  head  is 
rendered  of  less  dimensions  by  that  impaction, 
and  consequently  causes  a  less  projection  of  the 
deltoid.  The  difficulty  of  obtaining  crepitus  in 
non-impacted  fractures  will  be  obvious  when  the 
small  size  of  the  upper  fragment  is  considered, 
together  with  its  great  mobility,  and  the  obstacles 
in  the  way  of  so  fixing  it  that  one  broken  end 
may  be  rubbed  against  the  other.  The  diagnosis 
of  such  obscure  cases  is  now  cleared  up  by  the 
aid  of  the  X-rays. 

2.  Separation  of  the  upper  epiphysis. — The 
lower  border  of  this  epiphysis  is  represented  by  a 
line  crossing  the  bone  at  the  base  of  the  great 
tuberosity  and  placed  between  the  anatomical 
and  surgical  necks  (see  Fig.  60,  p.  261).  It  would 
be  fairly  indicated  by  a  transverse  saw-cut 
through  the  widest  part  of  the  bone.  The  three 
component  nuclei  of  this  epiphysis  (head,  greater 
and  lesser  tuberosities)  fuse  together  about  the 
fifth  year,  and  the  entire  mass  joins  the  shaft 
about  the  twentieth  year.  The  upper  fragment 
may  be  carried  and  rotated  a  little  outwards  by 
the  muscles  attached  to  the  great  tuberosity,  while 
the  lower  fragment  is  drawn  inwards  and  for- 
wards by  the  muscles  inserted  into  the  bicipital 
groove.  Thus,  a  part  of  the  smooth  upper  end  of 


xi]  FRACTURES   OF  HUMERUS  273 

the  lower  fragment  commonly  forms  a  distinct 
projection  below  the  coracoid  process.  In  such 
case  the  axis  of  the  limb  would  be  altered,  and 
the  elbow  carried  a  little  from  the  side.  Often, 
however,  the  displacement  is  solely  in  the  antero- 
posterior  direction,  the  lower  fragment  project- 
ing forwards.  So  wide  are  the  two  bone  surfaces 
at  the  seat  of  injury  that  it  is  scarcely  possible 
for  them  to  overlap  one  another. 

3.  Surgical  neck. — The  surgical  neck  is  situated 
between  the  bases  of  the  tuber  osities  and  the  in- 
sertions of  the  latissimus  dorsi  and  teres  major 
muscles.  A  common  displacement  of  parts  is  the 
following :  The  upper  fragment  is  carried  out 
and  rotated  put  by  the  supra-  and  infraspinatus 
and  teres  minor.  The  upper  end  of  the  lower 
fragment  is  drawn  upwards  by  the  deltoid,  biceps, 
coraco-brachialis,  and  triceps,  inwards  by  the 
muscles  attached  to  the  bicipital  groove,  and  for- 
wards by  the  great  pectoral.  Thus  it  forms  a 
projection  in  the  axilla,  and  the  axis  of  the  limb 
is  altered  so  that  the  elbow  projects  from  the  side. 
This  displacement,  however,  is  by  no  means  con- 
stant. Pean,  Anger,  and  others  maintain  that  the 
usual  deformity  is  a  projection  of  the  upper  end 
of  the  lower  fragment  forwards,  and  that  this 
deviation  is  due  to  the  nature  and  direction  of 
the  violence,  and  not  to  muscular  action.  In  some 
cases  there  is  no  displacement,  the  broken  ends 
being  retained  in  situ,  probably  by  the  biceps 
tendon  and  the  long  head  of  the  triceps.  In  at 
least  one  instance  (Jarjavay)  the  lower  fragment 
was  so  drawn  upwards  and  outwards,  apparently 
by  the  deltoid,  as  nearly  to  pierce  the  skin  of  the 
shoulder.  Hamilton  comes  to  the  general  con- 
clusion "  that  complete  or  sensible  displacement 
is  less  common  at  this  fracture  than  in  most  other 
fractures,"  and  in  this  conclusion  many  surgeons 
agree. 

Amputation  at  the  shoulder-joint. — The  deltoid 
muscle  forms  an  ideal  amputation  flap.  It  has 
its  blood  and  nerve  supply  secured  for  it  by  the 


274  THE    UPPER    EXTREMITY 

posterior  circumflex  vessels  and  circumflex  nerve, 
which  require  to  be  avoided  as  the  flap  is  raised 
from  the  posterior  aspect  of  the  upper  extremity 
of  the  humerus  prior  to  division  of  the  capsule. 
The  coracoid  process  lies  under  the  anterior  border 
of  the  muscle,  and  immediately  external  to  the 
line  of  the  axillary  vessels.  Thence  the  preliminary 
incision,  which  commences  just  externally  to  the 
coracoid,  and  is  carried  down  the  arm  along  the 
anterior  border  of  the  muscle,  gives  access  to  the 
axillary  vessels  so  that  they  may  be  secured  below 
the  origin  of  the  superior  profunda  (deep  artery 
of  arm).  The  incision  is  carried  backwards  above 
the  insertion  of  the  deltoid  to  the  humerus.  The 
insertion  of  the  pectoralis  major  is  cut  in  the 
incision  along  the  anterior  border  of  the  deltoid ; 
so  are  the  latissimus  dorsi  and  teres  major. 
The  insertions  of  the  teres  minor,  infraspinatus, 
supraspinatus,  and  subscapularis  are  adherent  to 
the  capsule  and  are  cut  through  with  it,  so  as 
to  free  the  head  of  the  bone.  The  lower  part 
of  the  capsule  and  the  long  head  of  the  triceps 
are  severed  after  the  head  of  the  humerus  has 
been  raised  from  its  socket  through  the  upper 
wound. 

In  excision  of  the  head  of  the  humerus  for 
disease  of  the  shoulder-joint,  an  incision  is  made 
along  the  line  of  the  tendon  9f  the  supraglenoid 
head  of  the  biceps,  the  incision  being  deepened 
until  the  tendon  is  exposed  within  the  joint. 
The  structures  cut  through  in  clearing  the  humeral 
head  have  been  enumerated  above,  in  connexion 
with  amputation  at  the  shoulder-joint.  It  must  be 
remembered,  while  excising  the  head,  that  four- 
fifths  of  the  growth  in  length  of  the  humeral 
shaft  takes  place  at  the  upper  epiphyseal  line, 
and  that  care  must  therefore  be  taken  to  avoid 
damage  to  that  line  in  the  young. 


CHAPTER   XII 
THE   ARM 

THE  arm,  upper  arm,  or  brachial  region  is  con- 
sidered to  extend  from  the  axilla  above  to  the 
region  of  the  elbow  below. 

Surface  anatomy. — In  women,  and  in  those 
who  are  fat,  the  outline  of  the  arm  is  rounded 
and  fairly  regular.  It  is  less  regular  in  the  mus- 
cular, in  whom  it  may  be  represented  by  a 
cylinder,  somewhat  flattened  on  either  side*  and 
unduly  prominent  in  front  (biceps  muscle).  The 
outline  of  the  biceps  muscle  is  distinct,  and  on 
either  side  of  it  is  a  groove.  The  inner  of  the 
two  grooves  is  by  far  the  more  conspicuous.  It 
runs  from  the  bend  of  the  elbow  to  the  axilla,  and 
indicates  generally  the  position  of  the  basilic  vein 
and  brachial  artery.  The  outer  groove  is  shal- 
low, and  ends  above  at  the  insertion  of  the  deltoid 
muscle.  So  far  as  it  goes  it  marks  the  position 
of  the  cephalic  vein. 

The  insertion  of  the  deltoid  is  an  important 
landmark,  and  can^  be  easily  distinguished.  It 
indicates  very  precisely  the  middle  of  the  shaft 
of  the  humerus,  is  on  the  same  level  with  the 
insertion  of  the  .coraco-brachialis  muscle,  and 
marks  the  upper  limit  of  the  brachialis.  It 
corresponds  also  to  the  spot  where  the  cylindrical 
part  of  the  humeral  shaft  joins  the  prismatic 
portion,  to  the  point  of  entrance  of  the  nutrient 
artery,  and  to  the  level  at  which  the  musculo- 
spiral  nerve  and  profunda  artery  of  the  arm 
cross  the  back  of  the  bone. 

When  the  arm  is  extended  and  supinated,  the 
brachial  artery  corresponds  to  a  line  drawn  along 
275 


276  THE    UPPER    EXTREMITY  [CHAP. 

the  inner  border  of  the  biceps,  from  the  outlet  of 
the  axilla  (at  the  junction  of  its  middle  and  an- 
terior thirds)  to  the  middle  of  the  bend  of  the 
elbow.  The  artery  is  superficial,  and  can  be  felt 
in  its  entire  extent.  In  its  upper  two-thirds  it 
lies  on  the  inner  aspect  of  the  shaft  of  the 
humerus,  and  can  be  compressed  against  the  bone 
by  pressure  in  a  direction  outwards  and  slightly 
backwards.  In  its  lower  third  the  humerus  lies 
behind  it,  and  compression,  to  be  effectual,  should 
be  directed  backwards. 

The  superior  ulnar  collateral  (inferior  pro- 
funda)  would  be  represented  by  a  line  drawn 
from  fhe  inner  side  of  the  humeral  shaft  at  its 
middle  to  the  back  part  of  the  internal  or  medial 
epicondyle.  The  nutrient  artery  enters  the  bone 
at  its  inner  aspect  opposite  the  deltoid  insertion, 
and  the  inferior  ulnar  collateral  (anastomotica 
magna)  vessel  comes  off  about  2  inches  above  the 
bend  of  the  elbow. 

The  ulnar  nerve  follows  first  the  brachial 
artery,  and  then  a  line  drawn  from  the  inner  side 
of  that  vessel,  about  the  level  of  the  insertion  of 
the  coraco-brachialis,  to  the  gap  between  the  inner 
condyle  and  the  olecranon.  The  main  part  of  the 
internal  or  medial  cutaneous  nerve  of  the  fore- 
arm is  beneath  the  inner  bicipital  groove,  while 
the  musculo-cutaneous  nerve  becomes  superficial 
in  the  bend  of  the  elbow  at  the  outer  margin  of 
the  tendon  of  the  biceps  in  the  outer  bicipital 
groove  or  sulcus.  Deep  in  this  groove  are 
found  two  nerves,  the  musculo-cutaneous  and 
the  musculo-spiral  (radial),  the  first  emerging 
from  beneath  the  biceps,  the  second  lying  beneath 
and  covered  by  the  proximal  part  of  the  brachio- 
radialis. 

The  skin  of  the  arm  is  thin  and  smooth, 
especially  in  front  and  at  the  sides.  It  is 
very  mobile,  being  but  loosely  attached  _to  the 
deeper  parts  by  a  lax  subcutaneous  fascia.  In 
circular  amputations  of  the  arm  this  looseness  of 
the  integument  allows  it  to  be  sufficiently  drawn 


xn]  BRACHIAL  APONEUROSIS  277 

up  by  traction  with  ;fchc  hand  only.  It  is  from 
the  integument  covering  the  anterior  surface  of 
the  biceps  that  the  flap  is  fashioned  in  Taglia- 
cozzi's  operation  for  the  restoration  of  the  nose. 
The  fineness  of  the  skin  of  this  part,  and  its 
freedom  from  hairs,  render  it  very  suitable  f9r 
this  procedure.  The  scanty  attachments  of  the  skin 
of  the  arm  allow  it  to  be  readily  torn  or  stripped 
away  in  lacerated  and  contused  wounds.  Some- 
times in  these  lesions  large  flaps  of  integument 
are  violently  dissected  up.  The  looseness  of  the 
subcutaneous  tissues  favours  greatly  the  spread 
of  inflammatory  processes,  while  its  comparative 
thinness  allows  of  the  early  manifestation  of 
ecchymoses. 

The  limb  is  completely  invested  with  a  deep 
fascia,  the  brachial  aponeurosis,  ^  as  by  a  sleeve. 
The  fascia  is  held  down  at  the  sides  by  the  two 
intermuscular  septa  which  are  attached  along  the 
outer  and  inner  margins  of  the  humerus,  running 
from  the  deltoid  insertion  to  the  outer  or  lateral 
epicondyle  on  the  one  side,  and  from  the  coraco- 
brachialis  insertion  to  the  inner  epicondyle  on 
the  other.  By  means  of  this  aponeurosis  and  its 
septa  the  arm  is  divided  into  two  compartments, 
which  can  be  well  seen  in  transverse  sections  of 
the  limb  (Fig.  63,  p.  281).  These  compartments 
serve  to  confine  inflammatory  and  hsemorrhagic 
effusions.  The  anterior  of  the  two  spaces  has  the 
less  substantial  boundaries,  owing  to  the  thinness 
of  the  brachial  fascia  as  it  covers  the  biceps. 
Effusions  can  readily  pass  from  one  compart- 
ment to  the  other  by  following  the  course  of  those 
structures  that,  by  piercing  the  intermuscular 
septa,  are  common  to  both  spaces :  these  are  the 
musculo-spiral  and  ulnar  nerves,  the  profunda 
artery,  the  superior  and  inferior  ulnar  collaterals. 
The  principal  structures  that  pierce  the  brachial 
aponeurosis  itself  are  the  basilic  vein,  a  little 
below  the  middle  of  the  arm,  the  internal  cuta- 
neous nerve  of  the  forearm,  about  the  middle,  and 
the  external  cutaneous  nerve  of  the  musculo- 


278  THE    UPPER    EXTREMITY  [CHAP. 

cutaneous,  at  the  elbow.  The  two  first-named 
are  in  the  inner  bicipital  groove,  and  the  last- 
named  is  in  the  outer. 

The  brachialis  is  closely  adherent  to  the  bone, 
while  the  biceps  is  free.  It  follows,  therefore, 
that  in  section  of  these  muscles,  as  in  amputa- 
tion, the  latter  muscle  retracts  more  consider- 
ably than  does  the  former.  It  is  well,  therefore, 
in  performing  a  circular  amputation,  to  divide 
the  biceps  muscle  first,  and  then,  after  it  has 
retracted,  to  cut  the  brachialis  anticus. 

Brachial  artery. — The  line  of  this  vessel 
has  already  been  given  (see  p.  275).  It  is  well  to 
note  that  in  the  very  muscular  the  artery  may  be 
overlapped  to  a  considerable  extent  by  the  biceps 
muscle.  Compression  of  the  brachial,  unless  per- 
formed carefully  with  the  fingers,  can  hardly 
avoid  at  the  same  time  compression  of  the  median 
nerve.  It  must  also  be  remembered  that  the  in- 
ternal cutaneous  ^  nerve  lies  in  front  of  the  vessel, 
or  close  to  its  inner  side,  until  it  pierces  the 
fascia;  that  the  ulnar  nerve  lies  along  the  inner 
side  of  the  artery  as  far  as  the  coraco-brachialis 
insertion ;  and  that  behind  the  commencement  of 
the  vessel  is  the  musculo-spiral  nerve.  The  venae 
comites  are  placed  one  on  either  side  of  the  artery, 
and  communicate  frequently  with  one  another  by 
short  transverse  branches  which  directly  cross  the 
vessel,  and  which  may  give  trouble  in  operations 
upon  the  artery.  If  in  ligaturing  the  artery  at 
its  middle  third  the  arm  rests  upon  any  sup- 
port, the  triceps  may  be  pushed  up  and  mistaken 
for  the  biceps.  If  the  ^  incisions  be  too  much 
to  the  inner  side  the  basilic  vein  may  be  cut,  or 
the  ulnar  nerve  exposed  and  mistaken  for  the 
median.  Tillaux  states  that  in  the  operation  a 
large  superior  ulnar  collateral  artery  has  been 
taken  for  the  brachial.  Inasmuch  as  the  median 
nerve  often  derives  distinct  pulsation  from  the 
subjacent  vessel,  it  happens  that  in  the  living 
subject  it  has  been  confused  with  the  main 
artery  itself. 


xii]  MUSCULO-SPIRAL   NERVE  279 

Abnormalities  in  the  arrangement  of  the  bra- 
chial  artery  are  so  frequent  (they  occur  in  12 
to  15  per  cent,  of  arms)  as  to  be  of  surgical  im- 
portance. It  is  not  unusual  to  find  a  collateral 
branch  (vas  aberrans)  arising  from  the  upper 
part  of  the  brachial  or  lower  part  of  the  axillary, 
passing  down  the  arm,  superficially  to  the  median 
nerve  and  ending  in  the  radial  or  sometimes  the 
ulnar  artery.  The  vas  aberrans  may  replace  the 
brachial,  in  which  case  the  artery  will  be  found 
superficial  instead  of  deep  to  the  median  nerve, 
and  the  profunda  or  deep  artery  and  the  superior 
ulnar  collateral  will  arise  from  the  remnant  of 
the  real  brachial  artery.  This  superficial  brachial 
vessel  may  pass  under  the  supracondyloid  process, 
a  hooked  projection  of  bone  which  occasionally 
springs  from  the  burner  us,  2  inches  above  the 
internal  epicondyle.  It  is  situated  among  the 
inner  fibres  of  origin  of  the  brachialis. 

The  iiins«>iilo-s|>ir:il  (radial)  nerve,  from  its 
close  contact  with  the  bone,  which  it  crosses  at  the 
level  of  the  deltoid  insertion,  is  frequently  injured 
and  torn.  Thus,  it  has  been  damaged  in  severe 
contusions,  in  kicks,  in  stabs,  in  bites  from  horses, 
and  very  frequently  in  fractures  of  the  humeral 
shaft;  or  the  nerve  may  be  sound  at  the  time 
of  fracture  and  become  subsequently  so  involved 
in  callus  as  to  lead  to  paralysis  of  the  parts  it 
supplies.  In  a  case  reported  by  Tillaux,  where 
paralysis  followed  some  time  after  a  fracture, 
the  nerve  was  found  embedded  in  callus,  and 
on  cutting  some  of  the  redundant  mass  away  a 
good  recovery  followed.  In  several  instances  the 
nerve  has  been  paralysed  by  the  pressure  of  the 
head  when  a  man  has  slept  with  his  head  Cresting 
on  the  arm  in  the  position  of  full  supination  and 
abduction.  It  is  said  to  be  often  paralysed  in 
Russian  coachmen  who  fall  asleep  with  the  reins 
wound  round  the  upper  arm.  It  has  also  been 
frequently  damaged  by  the  pressure  of  badly  con- 
structed crutches,  especially  those  that  afford  no 
proper  support  for  the  hand.  Indeed,  it  is  the 


280  THE    UPPER    EXTREMITY  [CHAP. 

nerve  most  often  affected  in  "crutch  paralysis," 
the  ulnar  being  the  trunk  that  suffers  next  in 
frequency. 

Fracture  of  the  shaft  of  the  humeriis  is 

usually  due  to  direct  violence.  The  shaft  may, 
however,  be  broken  by  indirect  violence,  and  of  all 
bones  the  humerus  is  said  to  be  the  one  most 
frequently  fractured  by  muscular  action.  As  ex- 
amples of  the  latter  may  be  noted  the  throwing 
of  a  ball,  the  clutching  at  a  support  to  prevent  a 
fall,  and  the  so-called  trial  of  strength  known  as 
"  wrist-turning."  Instances  of  muscular  fracture  of 
the  humerus  occur  among  soldiers  while  practising 
bomb-throwing.  When  the  bone  is  broken  above 
the  deltoid  insertion  the  lower  fragment  may  be 
drawn  upwards  by  the  biceps,  triceps,  and  del- 
toid, and  outwards  by  the  last-named  muscle; 
while  the  upper  fragment  is  drawn  inwards  by  the 
muscles  attached  to  the  bicipital  groove.  When 
the  fracture  is  below  the  deltoid  insertion,  the 
lower  end  of  the  upper  fragment  may  be  carried 
outwards  by  that  muscle,  while  the  lower  frag- 
ment is  drawn  upwards  to  its  inner  side  by  the 
biceps  and  triceps.  The  deformity,  however,  as 
a  rule  depends  much  more  upon  the  nature  and 
direction  of  the  force  that  breaks  the  bone  than 
upon  any  muscular  action.  The  displacements 
just  noted  may  be  met  with,  but  usually  they  are 
quite  independent  of  the  relation  of  the  deltoid 
insertion  to  the  seat  of  fracture,  and  cannot  be 
tabulated.  The  weight  of  the  arm  seldom  allows 
of  more  than  f  of  an  inch  of  shortening. 

Fracture  of  a  bone  is  always  attended  by  a  reflex 
contraction  of  the  muscles  surrounding  that  bone 
— a  reflex  set  up  by  injury  to  the  sensory  nerves 
which  end  in  the  damaged  bone,  periosteum,  and 
musculature;  hence  the  overriding  of  the  broken 
ends.  The  reflex  contraction  ceases  when  the 
patient  is  anaesthetized,  and  the  fragments,  which 
could  not  be  set  before,  can  now  be  brought  into 
apposition  with  ease. 

The  humerus   is  more   frequently   the  seat  of 


xn]  FRACTURES  OF  HUMERUS :   NON-UNION   281 


non-union  after  fracture  than  is  any  other  bone. 
This  result  is  quite  independent  of  the  position 
of  the  fracture  in  relation  to  the  nutrient  artery. 
Non-union  and  delayed  union  are  entirely  due 
to  the  difficulty  in  obtaining  fixation  or  im- 
mobilization of  the  humeral  fragments.  Perfect 
immobilization  to  secure  the  rest  necessary  for 
repair  can  only  be  obtained  by  preventing  all  the 
muscles  which  act 

on    any    part    of  ~%  .  fc  ,. 

the  humerus  from 
disturbing  the  site 
of   fracture.      Im- 
mobilization of  the 
humeral  muscles  is 
obtained  by  fixing 
all   the   joints    on 
which    they    act — 
the  shoulder-joint, 
the   elbow  -joint, 
the      wrist-      and 
hand- joints  —  for 
muscles     with     a 
humeral       attach- 
ment   act    on    all 
of      these     joints.   Fig.  63. — Transverse  sect  Jon  through 
Now,    immobiliza-      the  middle  of  the  arm.     (Braime.) 
tion  of  the  elbow,    a,  Biceps ;  b.  coraco-brachialis ;  c,  brachi- 
Wrist,      and     hand          alis  (anticus) ;  rf,  triceps  ;   1,  brachial 
artery  :    2,  median  nerve  :    3,  ulnar 

IS     easy,      but     no          nerve;     4,    musculo  -  spiral    (radial) 
means     have     yet        nerve, 
been  devised  which 

will  keep  the  shoulder-joint  at  rest.  Another 
cause  would  appear  to  be  the  entanglement  of 
muscular  tissue  between  the  broken  ends,  for  it 
must  be  remembered  that  the  shaft  of  the  bone 
is  closely  surrounded  by  adherent  muscular  fibres. 
Thus,  in  an  oblique  fracture  the  end  of  one 
fragment  may  be  driven  into  the  brachialis,  while 
the  other  end  projects  into  the  substance  of  the 
triceps,  and  immediate  contact  of  the  bones  may 
be  consequently  prevented. 


282  THE    UPPER    EXTREMITY 

Amputation  through  the  middle  of  the 
arm. — The  parts  divided  in  a  circular  amputation 
are  fully  shown  in  Fig.  63.  In  the  flap  method 
there  is  a  danger  of  transfixing  the  brachial 
artery.  The  artery,  as  may  be  seen  from  Fig.  63, 


be  secured  at  the  inner  border  of  the  biceps. 
In  the  anterior  flap  are  included  the  biceps, 
the  greater  part  of  the  brachialis  anticus,  with 
the  musculo-cutaneous  nerve  between  them,  and 
a  small  piece  of  the  triceps  from  the  inner  side 
of  the  limb.  In  the  posterior  flap  are  the  triceps, 
any  small  part  of  the  outer  portion  of  the 
brachialis  not  included  in  the  anterior  flap,  the 
superior  profunda  artery,  and  the  musculo-spiral 
nerve. 

Growth  of  the  humerus. — About  the  seven- 
teenth or  eighteenth  year,  growth  ceases  in  the 
distal  epiphyseal  line,  and  the  lower  or  distal 
epiphysis  becomes  united  to  the  shaft.  Growth 
ceases  much  later  at  the  proximal  or  upper 
epiphyseal  line,  the  proximal  epiphysis  joining 
with  the  shaft  about  the  twenty-first  or  twenty- 
second  year.  With  the  closure  of  the  epiphyseal 
lines,  growth  in  length  ceases.  Digby  has  esti- 
mated that  growth  in  length  takes  place  four 
times  more  rapidly  at  the  proximal  than  at  the 
distal  line.  Hence  injury  to  the  proximal  epiphy- 
seal line  in  a  growing  child  will  give  rise  to  a 
much  greater  degree  of  shortening  than  a  similar 
injury  to  the  distal  line. 


CHAPTER    XIII 
THE   REGION   OF   THE   ELBOW 

Surface  anatomy. — On  the  anterior  aspect  of 
the  elbow  are  seen  three  muscular  elevations. 
One,  above  and  in  the  centre,  corresponds  to  the 
biceps  and  its  tendon ;  while,  of  the  two  below  and 
at  the  sides,  the  outer  corresponds  to  the  brachio- 
radialis  and  the  common  extensor  mass,  and 
the  inner  to  the  pronator  teres  and  the  common 
set  of  flexor  muscles.  The  arrangement  of  these 
elevations  is  such  that  two  grooves  are  formed, 
one  on  either  side  of  the  biceps  and  its  tendon. 
The  grooves  diverge  above,  and  join  the  outer  and 
inner  bicipital  grooves,  while  below  they  meet 
over  the  most  prominent  part  of  the  tendon,  and 
thus  form  together  a  V-shaped  depression  (Fig. 
64).  The  distinctness  of  these  details  depends 
upon  the  thinness  and  muscular  development  of 
the  individual.  In  the  inner  of  the  two  grooves 
are  to  be  found  the  median  nerve,  the  brachial 
artery  and  its  veins;  while  deeply  placed  below 
the  outer  groove  are  the  terminations  of  the  mus- 
culo-spiral  (radial)  nerve  and  profunda  artery, 
with  the  small  radial  recurrent  vessel.  The  biceps 
tendon  can  generally  be  felt  distinctly.  Its  outer 
border  is  more  evident  than  is  its  inner  edge, 
owing  to  the  connexion  of  the  bicipital  fascia 
(lacertus  fibrosus)  with  the  latter  side  of  the 
tendon.  Extending  transversely  across  the  front 
of  this  region  is  a  crease  in  the  integument, 
the  ."fold  of  the  elbow."  This  fold  is  not  a 
straight  line,  but  is  convex  below.  It  is  placed 
some  little  way  above  the  line  of  the  articulation, 
and  its  lateral  terminations  correspond  to  the 
283 


284  THE    UPPER    EXTREMITY          [CHAP. 

tips  of  the  two  epicondylar  eminences.  In  back- 
ward dislocations  of  the  elbow  the  lower  end  of 
the  humerus  appears  about  1  inch  below  this 
fold,  whereas  in  a  fracture  of  the  humerus  just 
above  the  epicondyles  the  fold  is  either  opposite 
to  the  prominence  formed  by  the  lower  end  of 
the  upper  fragment,  or  is  below  it.  This  crease 
is  obliterated  on  extension. 

At  the  apex  of  the  V-shaped  depression,  about 
the  spot  where  the  biceps  tendon  ceases  to  be  dis- 
tinctly felt,  and  at  the  outer  side  of  that  tendon, 
the  median  vein  divides  into  the  median  basilic 
and  the  median  cephalic.  At  the  same  spot  also 
the  deep  median  vein  joins  the  superficial  vessels. 
The  median  basilic  vein  can  be  seen  to  cross  the 
biceps  tendon,  to  follow  more  or  less  closely  the 
groove  along  the  inner  border  of  the  muscle, 
and  to  join,  a  little  above  the  internal  (medial) 
epicondyle  with  the  posterior  ulnar  vein  to  form 
the  basilic  trunk.  The  median  cephalic,  follow- 
ing the  groove  at  the  outer  margin  of  the  biceps, 
joins,  about  the  level  of  the  external  (lateral) 
epicondyle,  with  the  radial  vein  to  form  the 
cephalic  vein.  The  brachial  artery  bifurcates 
1  inch  below  the  centre  of  a  line  drawn  from  one 
epicondyle  to  the  other;  the  point  of  division  is 
opposite  the  neck  of  the  radius.  "The  coronoid 
process  of  the  ulna  can  be  indistinctly  felt,  if 
firm  pressure  is  made  in  the  triangular  space  in 
front  of  the  joint"  (Chiene).  The  points  of  the 
two  epicondyles  can  always  be  felt.  The  internal 
epicondyle  is  the  more  prominent  and  the  less 
rounded  of  the  two.  The  humero-radial  articula- 
tion is  in  a  horizontal  line,  but  the  humero-ulnar 
joint  is  oblique,  the  joint  surfaces  sloping  down- 
wards and  inwards.  Thus  it  happens  that  while 
the  external  epicondyle  is  only  f  of  an  inch  (18  mm.) 
above  the  articular  line,  the  point  of  the  internal 
epicondyle  is  more  than  1  inch  (28  mm.)  above  that 
part  (Paulet).  From  the  obliquity  of  the  joint 
surfaces  between  the  ulna  and  humerus,  it  follows 
that  the  forearm,  when  in  extension,  is  not  in  a 


xin]  THE   ELBOW-JOINT  285 

straight  line  with  the  upper  arm,  but  forms  with 
it  an  angle  that  opens  outwards.  Thus,  when 
traction  is  made  upon  the  entire  upper  limb  from 
the  wrist,  some  of  the  extending  force  is  neces- 
sarily lost,  and  such  traction,  therefore,  should 
be  applied  from  the  elbow,  as  is  the  usual  practice 
in  reducing  a  dislocation  of  the  shoulder  by 
manipulation.  A  line  drawn  through  the  two 
epicondyles  will  be  at  right  angles  with  the  axis 
of  the  upper  arm,  while  it  will  form  externally  a 
smaller  angle  with  the  axis  of  the  forearm.  Thus, 
if  we  look  at  the  upper  arm,  the  two  epicondyles 
are  on  the  same  level,  whereas,  when  viewed  from 
the  forearm,  the  inner  epicondyle  lies  at  a  higher 
level  than  does  the  external  process. 

The  joint-line  of  the  elbow  is  equivalent  only 
to  about  two-thirds  of  the  width  of  the  entire  line 
between  the  points  of  the  two  condyles  (Fig.  66, 
p.  298).  The  prominence  of  the  condyles  forms  a 
capital  point  d'appui  for  traction  by  encircling 
bands  applied  to  the  limb  above  the  elbow-joint. 
At  the  back  of  the  elbow  the  prominence  of  the 
olecranon  is  always  to  be  distinctly  felt.  It  lies 
nearer  the  internal  than  the  external  epicondyle. 
In  extreme  extension  the  summit  of  the  olecranon 
is  a  little  above  the  line  joining  the  two  condyles. 
When  the  forearm  is  at  right  angles  with  the  arm, 
the  tip  of  the  process  is  below  the  line  of  the 
epicondyles,  and  in  extreme  flexion  it  lies  wholly 
in  front  of  that  line.  Between  the  olecranon  and 
the  inner  epicondyle  is  a  depression  that  lodges 
the  ulnar  nerve  and  the  dorsal  (posterior)  ulnar 
recurrent  artery. 

To  the  outer  side  of  the  olecranon,  and  just 
below  the  external  epicondyle,  there  is  a  depression 
in  the  skin  which  is  very  obvious  when  the  limb 
is  extended.  This  pit  is  to  be  seen  even  in  those 
who  are  fat,  and  also  in  young  children.  In  it 
the  head  of  the  radius  and  radio-humeral  joint 
can  be  felt,  and  can  be  well  distinguished  when 
the  bone  is  rotated  in  pronation  and  supination. 
The  pit  corresponds  to  the  hollow  between  the 


286 


THE    UPPER    EXTREMITY 


[CHAP. 


outer  border  of  the  anconeus  and  the  muscular 
eminence  formed  by  the  two  radial  extensors  of 
the  carpus  and  the  brachio- 
radialis.  The  highest  point 
of  the  bone  that  can  be 
felt  moving  on  rotation  will 
correspond  to  the  radius 
immediately  below  the  line 
of  the  elbow-joint,  and  is 
a  valuable  guide  to  that 
articulation.  The  upper 
limit  of  the  elbow-joint 
reaches  a  line  drawn  between 
the  point  of  the  two  epi- 
eondyles.  The  tuberosity  of 
the  radius  can  be  felt  just 
below  the  head  of  the  bone 
when  the  limb  is  in  the 
position  of  extreme  pron- 
ation. 

The    skin    in    front    of 
the  elbow  is  thin  and  fine, 
and    is    readily    excoriated 
by  tight  bandaging  and  by 
\~,  .:]  improperly  applied  splints. 

The    thinness    of    the    skin 

Fig.   64. — Left   elbow     allows   the   subjacent    veins 
from  in  front.  to    be    easily    seen    through 

a,  Basilic  vein ;   Z>,  cephalic   the      integuments,      but     the 

vein ;   c,  on   the   ulna,  distinctness     with     which 

"Doints  to  in  o(li  tin  iKisilic   11  •       •  i  i 

vein ;  d,  on  the  radius,  these  veins  appear  depends 
point's  to  median  cephalic  mainly  upon  the  amount  of 

vein;  e,  radial  vein;/,  qil^nilf nT1r,mia  -fof  Jn  ^n 
median  vein;  g,  posterior  SUDCUtaneOUS  lat.  In  tfie 
ulnarvein.  The  brachial  very  stoilt^  they  may  be 

divides  into  its  radial  and  be  difficult  Or   impossible   to 

ulnar  branches  to  the  render  them  evident  by  the 

nTck. Side  °f  the  mdial  llsual     means     adopted     in 

venesection. 
The  arrangement  of  the  superficial  veins  in 

front  of  the  elbow,   so  as  to  form  an   M -shaped 
figure,  is  familiar,  but  it  must  be  confessed  that 


xm]  MEDIAN   VEIN  287 

it  is  by  no  means  constant  (Fig.  64).  So  far  as 
I  (F.  T.)  have  seen,  it  would  appear  that  the 
precise  M-like  arrangement  figured  in  most  books 
is  only  present  in  about  two-thirds,  and  perhaps 
in  only  one-half,  of  all  cases. 

The  median  vein  breaks  up  into  the  median 
cephalic  and  median  basilic,  just  to  the  outer 
side  of  the  biceps  tendon,  and,  therefore,  the 
latter  vein  passes  in  front  of  the  tendon,  of  the 
brachial  artery  and  its  veins,  and  of  the  median 
nerve.  From  these  structures  it  is  separated  by 
the  bicipital  fascia.  The  median  basilic  vein  may 
cross  the  brachial  artery  abruptly,  and  be  com- 
paratively free  of  it,  except  at  the  point  of  ^cross- 
ing,  or  it  may  run  for  some  distance  quite  in 
front  of  the  artery,  or,  crossing  it  early,  may 
He  parallel  with  the  vessel,  although  at  a  different 
level,  for  the  greater  part  of  its  course.  As  re- 
gards size,  the  median  basilic  is  usually  the 
largest  of  these  veins,  the  median  cephalic  coming 
next,  and  the  median  itself  third,  while  the  ulnar 
and  radial  veins  are  the  smallest  of  the  series. 
These  veins  are  liable  to  many  abnormalities, 
some  of  the  most  conspicuous  being  in  cases  where 
the  main  arteries  of  the  part^also  are  abnormal. 
The  deviation  is  more  usual  in  the  veins -on^  the 
radial  than  in  those  on  the  ulnar  side  of  the  limb. 
Thus  it  is  common  for  the  radial  or  the  median 
cephalic  veins,  or  both,  to  be  either  very  defec- 
tive or  entirely  absent.  In  spite  of  the  relation 
the  median  basilic  vein  bears  to  the  brachial 
artery,  it  is  nevertheless  the  vein  usually  selected 
in  venesection  and  transfusion,  and  the  intravenous 
injection  of  sera  and  vaccines.  The  reasons  for 
its  selection  are  these  :  ifc  is  usually  the  largest 
and  most  prominent  of  the  veins,  and  the  one 
the  nearest  to  the  surface;  it  is  also  the  least 
movable  vein,  and  the  one  the  least  subject  to 
variation.  The  bicipital  fascia  forms  an  excel- 
lent protection  to  the  brachial  artery  during 
phlebotomy.  The  density  of  that  membrane 
varies,  and  depends  mainly  upon  the  degree  of 


288  THE    UPPER    EXTREMITY  [CHAP. 

muscular  development.  In  thin  subjects  the 
median  basilic  vein  may  receive  pulsations  from 
the  subjacent  artery.  According  to  one  observer, 
the  walls  of  this  vein  are  often  as  thick  as  those 
of  the  popliteal  vein.  The  ulnar,  radial,  and 
median  veins  seldom  yield  enough  blood  on  vene- 
section, since  they  are  below  the  point  of  junction 
of  the  deep  median  vein,  and  thus  do  not  receive 
blood  from  the  deep  veins  of  the  limb.  The 
brachial  artery  has,  as  may  be  supposed,  been 
frequently  injured  in  bleeding;  and  at  the  period 
when  venesection  was  very  commonly  practised, 
arterio-venous  aneurysms  at  the  bend  of  the  elbow 
were  not  infrequent.  Since  the  principal  super- 
ficial lymphatic  vessels  run  with  these  veins,  and 
since  some  of  them  can  scarcely  escape  injury  in 
phlebotomy,  it  follows  that  an  acute  lymphan- 
gitis is  not  uncommon  after  the  operation,  especi- 
ally when,  the  point  of  the  lancet  being  unclean, 
septic  matter  is  introduced  into  the  wound. 

The  internal  cutaneous  nerve  (medial  cuta- 
neous of  forearm),  which  usually  runs  in  front 
of  the  median  basilic  vein,  may  be  wounded 
in  bloodletting  from  that  vessel.  The  injury 
to  the  nerve,  according  to  Tillaux,  may  lead 
to  "  traumatic  neuralgia  of  extreme  intensity, 
and  very  chronic."  A  "  bent  arm  "  may  follow 
after  venesection,  and  Hilton  believes  this  to 
be  often  due  to  injury  to  the  filaments  of  the 
musculo-cutaneous  nerve,  especially  to  the  inclu- 
sion of  those  filaments  in  a  scar  left  by  the  opera- 
tion. The  cutaneous  branches  of  this  nerve  lie 
over  the  median  cephalic  vein.  These  peripheral 
fibres  being  irritated,  the  muscles  which  are  sup- 
plied from  the  same  segment  of  the  cord  (biceps 
and  brachialis)  are  caused  to  contract  by  reflex 
action.  Hence  the  bent  arm.  In  one  case  Hilton 
cured  a  bent  arm  following  bleeding  by  resecting 
the  old  scar,  which  on  removal  was  found  to 
have  included  within  its  substance  some  nerve 
filaments. 

There  is  a  lymphatic  (siipracubital)  gland 


xmj  BRACHIAL   ARTERY  289 

situated  over  the  internal  intermuscular  septum 
of  the  arm,  and  just  above  the  internal  epicondyle. 
It  receives  some  of  the  surface  lymphatics  from 
the  inner  side  of  the  forearm  and  two  or  three 
inner  fingers.  In  position  it  is  the  lowest  of 
the  constant  glands  in  the  upper  limb.  In  the 
same  position  occurs  an  occasional  bony  out- 
growth of  the  inner  aspect  of  the  humerus — the 
supracondyloid  process.  The  brachial  artery,  and 
also  the  median  nerve,  may  pass  beneath  and 
internally  (medially)  to  this  process. 

Brachial  artery* — In  forcible  flexion  of  the 
limb  the  artery  is  compressed^  between  the  mus- 
cular masses  in  front  of  the  joint,  and  the  radial 
pulse  is  much  diminished  or  even  checked.  The 
artery  may  divide  in  the  lower  third  of  the  arm, 
and  in  such  cases  the  ulnar  artery  may  pass 
over  the  bicipital  fascia.  Aneurysms  at  the  bend 
of  the  elbow  have  been  treated  by  flexion  of  the 
limb,  that  position  bringing  more  or  less  direct 
pressure  t9  bear  upon  the  sac.  In  full  extension 
of  the  joint  the  artery  becomes  flattened  out, 
and  the  radial  pulse  diminished.  In  the  over- 
extension  possible  with  fractured  olecranon  the 
pulse  may  be  stopped  at  the  wrist.  Forcible  ex- 
tension  of  an  elbow  that  has  become  rigid  in  the 
bent  position  has  caused  rupture  of  the  brachial 
artery. 

The  uliiar  nerve  is,  from  its  position  at  the 
elbow,  very  liable  to  be  injured.  It  passes  in 
a  groove  behind  the  internal  epicondyle,  and  is 
crossed  by  a  bridge  of  fibrous  tissue  which  pre- 
vents its  displacement.  The  nerve  may  pass  in 
front  of  the  internal  epicondyle,  and  an  instance 
is  reported  where  the  nerve  slipped  forwards 
over  that  eminence  whenever  the  elbow  was  bent 
(Quain).  In  exposing  the  ulnar  nerve  (for  nerve- 
stretching,  etc.)  behind  the  elbow  the  nerve  may 
be  found  quite  covered  by  an  occasional  muscle, 
the  epitrochleo-anconeus. 

The  elbow-joint.— The  strength  of  this  joint 
depends  not  so  much  upon  either  ligaments  or 


290  THE    UPPER    EXTREMITY  [CHAP. 

muscles  as  upon  the  coaptation  of  the  bony  sur- 
faces. The  relations  of  the  olecranon  and  coronoid 
processes  to  the  humerus  are  such  that  in  certain 
positions  the  strength  of  the  joint  is  very  con- 
siderable. 

The  elbow,  being  a  pure  hinge-joint,  permits 
only  of  flexion  and  extension.  These  movements 
are  oblique,  so  that  in  flexion  the  forearm  in- 
clines inwards,  carrying  the  hand  towards  the 
middle  third  of  the  clavicle.  m  If  it  were  not  for 
the  obliquity  of  the  joint  line  it  would  be  possible 
for  the  hand  to  be  placed  flat  upon  the  shoulder 
of  the  same  side;  but  this  movement  is  only  pos- 
sible after  some  excisions  of  the  joint,  for  in  this 
operation  the  oblique  direction  of  the  articular 
surfaces  is  not  reproduced.  In  extreme  extension 
the  ulna  is  nearly  in  a  straight  line  with  the 
humerus  as  regards  their  lateral  planes,  while 
in  extreme  flexion  the  two  bones  form  an  angle 
of  from  30°  to  40°. 

Bursse.  —  Of  the  bursse  about  the  joint  the 
large  subcutaneous  bursa  over  the  olecranon  is 
very  commonly  found  enlarged  and  inflamed 
(Fig.  65),  and  when  inflamed  may  lead  to  exten- 
sive mischief  in  the  limb.  Its  enlargement  is 
favoured  by  certain  employments  involving  pres- 
sure on  the  elbow;  thus,  the  disease  known  as 
"miner's  elbow"  is  merely  an  enlargement  of  this 
sac.  There  is  a  bursa  between  the  biceps  tendon 
at  its  insertion  and  the  bone,  the  relations  of  which 
to  the  nerves  of  the  forearm  are  worth  noting. 
A  case,  for  instance,  is  reported  where  this  bursa 
became  chronically  enlarged,  and  by  pressing 
upon  the  median  and  dorsal  interosseous  nerves 
produced  loss  of  power  in  the  forearm  (Agnew). 
There  is  a  small  bursa  at  the  insertion  of  the 
triceps  (Fig.  65). 

Of  the  ligaments  of  the  elbow- joint,  the  an- 
terior and  posterior  are  comparatively  thin,  and 
the  latter  especially  soon  yields  to  the  pressure  of 
fluid  within  the  joint  in  disease  of  the  articu- 
lation (Fig.  65).  The  internal  lateral  (ulnar 


XIII] 


LIGAMENTS   OF   ELBOW-JOINT 


291 


collateral)  ligament  is  the  strongest  and  most 
extensive  of  the  ligaments  of  the  part.  From 
its  rigidity,  its  extended  attachment,  and  the 
fact  that  it  serves  to  limit  not  only  flexion  and 
extension,  but  also  any  attempt  to  wrench  the 
forearm  laterally  from  the  arm,  it  happens  that 
it  is  the  ligament  that  suffers  the  most  often 
in  "sprains"  of  the  elbow.  As  this  ligament  is 
attached  to  the  whole  length  of  the  inner  border 


TR.  i  c  E  PO 


/1UMERU5 

BICEPS 
BRACMIALIS  AM 


CAPSULE 

SUP.  L.O/1CU5. 

EPIPAIYSIS  <jf  TROCMLE 
COR.O/SOID 

BUR.5A 


BICEPS 


Fig.  65. — Vertical  section  of  the  elbow-joint. 

The  epiphyseal  lines  of  the  plecranon  and  trochlea  are  shown  in  red. 
The  joint  is  semi-extended. 

A,  Usual  cap-like  cpiphysis  of  olecranon  receiving  insertion  of  tri- 

:  ceps ;  B,  occasional  epiphysis  forming  the  upper  third  of  the 

olecranon.    Three  bursao  are  shown — over  the  olecranon,  under 

the  insertion  of  the  triceps,  and  at  the  insertion  of  the  biceps. 

(Supinator  longus=brachio-radialis.) 

of  the  olecranon,  it  may  assist  in  preventing 
separation  of  the  fragments  when  that  process 
has  been  fractured. 

Joint  -  disease. — In  disease  of  this  joint,  tha 
effusion   first   shows   itself  by   a   swelling   around 


292  THE    UPPER    EXTREMITY  [CHAP. 

the  margins  of  the  olecranon.  This  is  explained 
by  the  facts  that  the  synovial  cavity  is  here 
nearest  to  the  surface,  and  that  the  posterior  liga- 
ment is  lax  and  thin  (Fig.  65).  Some  swelling 
is  also  soon  noticed  about  the  line  of  the  radio- 
humeral  joint,  and  fluctuation  in  this  situation 
serves  to  distinguish  joint-effusion  from  simple 
enlargement  of  the  bursa  beneath  the  triceps 
tendon.  Deep-seated  swelling  may  be  noted  about 
the  front  of  the  joint  beneath  the  brachialis 
anticus,  owing  to  the  thinness/of  the  anterior  liga- 
ment; and,  lastly,  about  the  external  epicondyle. 
The  density  of  the  internal  (ulnar  collateral)  liga- 
ment prevents  bulging  of  the  synovial  membrane 
on  the  inner  side.  When  the  joint  suppurates  the 
pus  will  most  easily  reach  the  surface  by  travel- 
ling upwards  and  backwards  between  the  humerus 
and  the  triceps,  and  the  abscess  points,  therefore, 
very  commonly  at  one  or  other  border  of"  that 
muscle.  The  pus  may  escape  beneath  the  brachi- 
alis in  front,  and  discharge  itself  near  the  in- 
sertion of  the  muscle.  The  diseased  elbow  tends 
to  assume  the  posture  of  semiflexion,  and  it  is 
interesting  to  observe  that  that  is  the  position 
assumed  by  the  joint  when  forcible  injections 
are  made  into  its  cavity  (Braune).  The  joint,  in 
fact,  holds  the  greatest  amount  of  fluid  when  it 
is  semiflexed.  As  regards  muscular  rigidity  of 
the  elbow,  due  to  reflex  irritation  from  disease, 
it  is  well  to  note  that  all  the  nerves  of  the  articu- 
lation, notably  the  musculo-spiral  and  musculo- 
cutaneous,  supply  muscles  acting  upon  the  joint. 
The  relation  of  the  ulnar  nerve  to  the  joint  serves 
to  explain  cases  where  severe  pain  has  been  felt 
along  the  forearm  and  in  the  fingers,  in  parts 
corresponding  to  the  distribution  of  that  nerve. 
The  upper  epiphysis  of  the  radius  and  the  greater 
part  of  the  lower  epiphysis^ of  the  humerus  are 
intrasynovial,  i.e.  come  within  the  capsule  of  the 
joint  (Fig.  66).  The  comparatively  small  upper 
epiphysis  of  the  ulna  is  only  partly  within  the 
capsule  (Fig.  65). 


xm]  THE  ELBOW-JOINT  293 

Dislocations  of  the  elbow. — These  are  many, 
and  may  be  thus  arranged.  (1)  Dislocations  of 
both  radius  and  ulna  either  backwards,  out- 
wards, inwards,  or  forwards  (in  order  of  fre- 
quency). (2)  Dislocations  of  the  radius  alone 
either  forwards,  backwards,  or  outwards  (in  order 
of  frequency).  (3)  Luxation  of  the  ulna  alone 
backwards. 

As  a  preliminary  it  may  be  convenient  to  note 
some  general  anatomical  considerations  in  con- 
nexion with  these  various  displacements. 

(a)  Antero-posterior  luxations  are  much  more 
common  than  lateral  luxations. — Displacements  in 
the  antero-posterior  direction  are  t  more  common 
because  the  movements  of  the  joint  take  place 
in  that  direction,  and  the  width  of  the  articular 
surface  of  the  humerus  from  before  backwards 
is  comparatively  small.  On  the  other  hand, 
there  is  normally  no  lateral  movement  of  the 
elbow,  and  the  width  of  the  articulation  from 
side  to  side  is  considerable.  The  antero-posterior 
ligaments  are  feeble,  while  the  lateral  (collateral) 
ligaments  are  strong. 

(6)  Both  bones  of  the  forearm  are  more  often 
luxated  together  than  is  either  the  radius  alone 
or  the  ulna  alone. — This  depends  upon  the  power- 
ful ligamentous  connexion  between  the  radius 
and  ulna  on  the  one  hand,  and  the  absence  of 
such  connexion  between  the  humerus  and  the 
radius  on  the  other.  In  the  dead  subject  it  is  not 
difficult  to  dislocate  the  two  bones  of  the  fore- 
arm, but  it  is  extremely  difficult  to  separate  the 
radius  from  the  ulna  without  great  breaking  and 
tearing  of  parts. 

(c)  The  commonest  dislocation  of  the  two  bones 
together  is  backwards,  the  rarest  is  forwards. — 
In  the  former  instance  the  movement  is  resisted  by 
the  small  coronoid  processv  in  the  latter  by  the 
large  and  curved  olecranon.  For  like  reasons  the 
luxation  outwards  is  less  rare  than  is  the  dis- 
placement inwards,  since  the  articular  surface  of 
the  humerus  inclines  downwards  and  inwards  on 


294  THE    UPPER    EXTREMITY          [CHA£ 

the  inner  side,  and  thus  affords  a  greater  obstacle 
in  that  quarter. 

(d)  If  a  single  bone  be  dislocated  it  will 
usually  be  the  radius. — This  follows  from  the 
absence  of  reliable  union  between  that  bone  and 
the  ^humerus,  from  the  greater  exposure  of  the 
radius  ("  the  handle  of  the  hand  ")  to  indirect 
violence,  and  from  its  greater  mobility.  The 
luxation  is  usually  forwards,  due  to  the  fact  that 
the  forms  of  violence  that  tend  most  often  to  dis- 
place the  bone  tend  also  to  draw  it  forwards. 
Paulet  asserts  that  the  posterior  part  of  the 
annular  ligament  is  "much  more  resistant"  than 
is  the  anterior  part.  The  luxation  of  the  ulna 
alone  occurs  in  the  backward  direction,  for  rea- 
sons that  will  be  obvious. 

Dislocations  of  all  kinds  may  be  partial  or 
complete.  More  usually  they  are  complete  when 
in  the  antero-posterior  direction,  and  partial 
when  the  luxation  ^is  lateral. 

Some  more  detailed  notice  may  now  be  taken 
of  the  only  two  forms  of  dislocation  at  the  elbow 
that  are  at  all  common. 

1.  Displacement  of  both  bones  backwards — This 
may  be  effected  during  forced  extension.  Here 
the  point  of  the  olecranon  pressed  against  the 
humerus  acts  as  the  fulcrum  of  a  lever  of  the 
second  kind,  with  the  result  that  the  sigmoid  or 
semilunar  notch  is  forced  away  from  the  trochlea. 
The  addition  of  violence  to  the  forearm  in  a  back- 
ward or  upward  direction  would  effect  the  actual 
displacement.  This  condition  may  be  illustrated 
by  a  fall,  when  running,  upon  the  fully  ex- 
tended hand.  The  lesion  may  also  be  produced 
by  certain  violent  wrenchings  of  the  limb.  Mal- 
gaigne  maintained  that  the  particular  kind  of 
wrench  most  effectual  in  producing  luxation  was 
a  twisting  inwards  of  the  forearm  while  the 
elbow  was  semiflexed.  In  this  way  the  internal 
lateral  ligament  was  ruptured,  and  the  coronoid 
process  twisted  inwards  and  downwards  under  the 
humerus,  and  the  bones  were  thus  displaced  back- 


xm]  SPRAIN  OF  THE  ELBOW  295 

wards.  This  lesion  would  be  difficult  to  effect  while 
the  joint  was  fully  flexed.  In  the  complete  form 
the  coronoid  process  is  opposite  to  the  olecranon 
fossa.  It  can  hardly  occupy  that  hollow  (as  some- 
times described),  since  the  connexion  of  the  ulna 
to  the  radius,  and  the  projection  of  the  latter 
bone  behind  the  outer  epicondyle,  would  prevent 
it  from  actually  falling  into  the  fossa.  The  an- 
terior and  the  two  lateral  ligaments  are  usually 
more  or  less  entirely  torn,  while  the  posterior 
and  annular  ligaments  escape.  The  biceps  is 
drawn  over  the  lower  end  of  the  humerus,  and 
is  rendered  moderately  tense.  The  brachialis  is 
much  stretched  and  often  torn.  The  anconeus  is 
made  very  tense.  Both  the  median  and  the  ulnar 
nerve  may  be  severely  stretched. 

2.  Dislocation  of  the  radius  forwards.  — This  may 
be  due  to  direct  violence  to  the  bone  from  behind, 
or  to  extreme  pronation,  or  to  falls  upon  the 
extended  and  pronated  hand.  The  anterior,  ex- 
ternal, and  annular  ligaments  are  torn. 

Sprain  of  tlie  elbow.— Mr.  J.  Hutchinson 
has  shown  that  in  young  children,  under  5  years, 
forcible  traction  of  the  limb  in  the  supinated 
position  may  cause  the  radius  to  slip  down- 
wards, away  from  the  annular  ligament,  which 
is  displaced  upwards.  In  such  cases  traction 
is  applied  before  the  muscles  of  the  elbow  have 
had  ^time  to  undergo  their  usual  ^  reflex  con- 
traction, so  that  when  the  child  is  lifted  by  the 
hand  all  the  weight  falls  upon  the  ligaments  at 
the  elbow  instead  of  on  the  muscles.  The  only 
ligaments  which  resist  such  a  dislocation  are  (1) 
the  oblique  ulno-radial  ligament,  (2)  the  lower 
fibres  of  the  annular  ligament  which  grip  the 
head.  Flexion  of  the  elbow  in  the  pronated  posi- 
tion restores  the  ligament  to  its  normal  situation. 
It  is  clear  that  this  displacement  is  the  anatomical 
basis  of  the  common  sprain  of  the  elbow  met  with 
in  young  children,  and  usually  due  to  violent 
traction  of  the  hand. 

Fractures  of  tlie  lower  end  of  the  liiimerus. 


296  THE    UPPER    EXTREMITY  [CHAP. 

— These  are:  (1)  A  fracture  just  above  the  epi- 
condyles; (2)  the  " T-shaped  fracture,"  involving 
the  joint;  (3)  fractures  of  the  internal  or  medial, 
and  (4)  of  the  external  or  lateral  condylar 
parts;  (5)  fracture  of  the  internal  epicpndyle; 
and  (6)  separation  of  the  lower  epiphysis.  All 
these  fractures  are  more  common  in  the  young. 

1.  The  fracture  "at  the  base  of  the  epicondyles," 
as  it  is  sometimes  called,  is  usually  situate  a  little 
above    the    olecranon    fossa,    where    the    humeral 
shaft  begins  to  expand.     It  is  commonly   trans- 
verse from  side  to  side,  and  oblique  from  behind 
downwards  and  forwards.     It  is  generally  the  re- 
sult of  a  blow  inflicted  upon  the  extremity  of  the 
elbow.     Probably  the  tip  of  the  olecranon  driven 
sharply  against  the  bone  acts  like  the  point  of 
a  wedge,   and  takes  an   important  share  in   the 
production  of  the  fracture.     The  lower  fragment, 
together  with  the  bones  of  the  forearm,  is  gener- 
ally  carried  backwards  by  the  triceps,   and  up- 
wards by  that  muscle,  the  biceps,  and  the  brachi- 
alis.     The  median  or  ulnar  nerves,  especially  the 
latter,  may  be  severely  damaged. 

2.  The  "T-shaped  fracture"  is   but   a   variety 
of  the  lesion  just  noted.     In  addition  to  the  trans- 
verse fracture  above  the  epicondyles,  there  is  also  a 
vertical  fracture  running  between  the  two  epicon- 
dyles into  the  joint.     The  lower  fragment  is  thus 
divided  into  two  parts.     The  displacement  is  the 
same.     The  fracture  is  usually  due  to  a  fall  upon 
the  bent  elbow,   and  here  possibly  the  tip  of  the 
olecranon  again  acts  as  a  wedge,   producing  the 
transverse   fracture,    while   the    prominent   ridge 
along  the  middle  of  the  semilunar  notch  of  the 
ulna,   acting    as    a    second    wedge,   produces    the 
vertical  fracture  into  the  joint. 

For  surgical  purposes  it  is  convenient  to  apply 
the  term  "condylar  part"  to  each  area  of  the 
distal  articular  extremity  of  the  humerus  on  which 
the  epicondyles  are  placed.  The  epicondyles  are, 
strictly  speaking,  outside  the  joint  capsule;  the 
"condylar  parts"  descend  within  it. 


xin]        FRACTURES   OF  THE   HUMERUS          297 

3.  In     fracture     of     the    internal     or     medial 
condylar    part  the    line    of    separation    generally 
commences  about  half  an  inch  above  the  tip   of 
the  medial  epicondyle  (and,  therefore,  outside  the 
joint),  and,  running  obliquely  outwards  through 
the    olecranon    and    coronoid    fossae,    enters    the 
articulation  through  the  centre  of  the  trochlear 
surface  (Hamilton).     The  fragment  is  often  dis- 
placed a  little  upwards,  backwards,  and  inwards, 
the  ulna  going  with  it. 

4.  In     fracture     of     the    external     or     lateral 
condylar    part    the    line    of    fracture    commences 
also  f above  the   external   epicondyle   and   outside 
the   joint,    and,    running   downwards,    enters   the 
joint  usually  between  the  trochlear  surface   and 
the  surface  for  the  radius.     The  displacement  is 
trifling  and  inconstant. 

5.  On  account  of  its  insignificant  size,  a  fracture 
of   the   external    epicondyle    is   scarcely    possible. 
Fractures    of    the    internal  or  medial   epicondyle 
are,  however,  quite  common,  the  joint  remaining 
free  (Fig.  66).    This  epicondyle  exists  as  a  distinct 
epiphysis,  which  unites  at  the  age  of  18,  and  which 
at  any  time  before  that  age  may  be  separated  from 
the  bone  bv   direct  injury  or  muscular  violence. 
Owing  to  the  dense  aponeurotic  fibres  that  cover 
the  part,  much  displacement  of  the  fragment  is 
uncommon.     When    displacement  exists,    it   is   in 
the  general  line  of  the  common  flexor  muscles  that 
arise  from  the  tip  of  the  process.     In  such  cases 
the  ulnar  nerve,  which  lies  behind  the  process,  is 
often   damaged. 

6.  The   lower  epiphysis  (Fig.  66). — In  the  car- 
tilaginous lower  extremity  of  the  humerus   four 
pssific  centres  appear,  one  for  each  of  the  follow- 
ing   parts  :f   capitellum,    trochlea,    external    and 
internal    epicondyles.      The   three   centres    named 
first  unite  to  form  the  main  epiphysis,  that  for  the 
internal  epicondyle  remaining  separate  (Fig.  66). 
The  epiphyseal  line  is  thus  divided  into  two  parts, 
and  is  irregular  in  form;  it  lies  both  within  and 
without  the  capsule  of  the  joint  (Fig.   66).     Its 


298 


THE    UPPER    EXTREMITY 


CHAP. 


position  may  be  indicated  by  a  line  drawn  from 
the  upper  border  of  the  external  to  the  lower 
border  of  the  internal  epicondyle.  The  lower 
epiphysis  joins  the  shaft  at  the  age  of  17.  Thus, 
after  17  the  growth  of  the  bone  must  depend  upon 
the  activity  of  the  upper  epiphysis,  which  does 
not  unite  until  20.  Excision  of  the  elbow,  there- 
fore, after  the  sixteenth  or  seventeenth  year,  will 
not  be  followed  by  arrest 
of  development  in  the 
limb,  even  if  the  epi- 
physeal  line  has  been 
transgressed  by  the  saw. 
Several  cases  are,  how- 
ever, reported  of  marked 
arrest  of  growth  in  the 
limb  following  upon  in- 
juries to  the  lower  epi- 
physis before  the  six- 
teenth year,  and  to  the 
upper  epiphysis  before 
20.  The  greater  part  of 
the  epiphyseal  line  being 
within  the  capsule,  but 
little  displacement,  other 
than  a  slight  movement 
backwards,  is  consequent 
upon  the  separation  of 
the  distal  mass. 

Fractures     of     the 
olecranonare  commonly 

by  red  lines.  due  to  direct  violence,  and 

in  a  few  cases  to  severe 

indirect  violence  applied  to  the  lower  end  of  the 
humerus  or  upper  end  of  the  ulna.  Instances  of 
fracture  by  muscular  action  are  few,  and  open 
to  some  question.  The  fracture  is  most  commonly 
met  with  about  the  middle  of  the  process,  just 
where  it  begins  to  be  constricted,  and  it  is  usually 
transverse  in  direction.  The  amount  of  displace- 
ment effected  by  the  triceps  varies,  and  depends 
upon  the  extent  to  which  the  dense  periosteum 


Fig.  66. — Lower  epiphysis  of 
the  humerus  from  behind. 

A,  Centre  for  internal  epicon- 
dyle ;  B,  C,  D,  united  centres 
for  the  trochlea,  capitellum, 
and  external  epicondyle  ;  E, 


xni]  FRACTURES   OF   THE   ULNA  299 

about  the  process  and  the  ligaments  that  are 
attached  to  it  are  torn.  The  olecranon  is  de- 
veloped mainly  from  the  shaft  of  the  ulna  (Fig. 
65).  There  is  a  scale-like  epiphysis,  however,  at 
the  summit  of  the  process  which  joins  the  rest 
of  the  olecranon  at  the  age  of  17.  Occasionally 
another  epiphyseal  centre  occurs,  giving  origin 
to  the  upper  third  of  the  olecranon  (Fig.  65). 
In  young  subjects  the  scale-like  epiphysis  may 
be  separated  by  violence,  or  the  cartilaginous 
olecranon  may  be  dissevered  from  the  rest  of  the 
bone.  The  common  fracture  of  the  adult  olecranon 
does  not  follow  the  epiphyseal  line. 

Fracture  of  the  coronoid  process  is  an 
extremely  rare  accident,  sometimes  occurring  in 
dislocation  backwards  of  the  ulna.  It  is  impos- 
sible to  understand  how  the  process  can  be  torn 
off  by  the  action  of  the  brachialis  anticus,  since 
that  muscle  is  inserted  rather  into  the  ulna  at 
the  base  of  the  projection  than  into  the  process 
itself  (Fig.  65).  Nor  can  it  be  separated  as  an 
epiphysis,  since  it  does  not  exist  as  such. 

Fractures  of  the  head  or  neck  of  the  radius 
are  rare,  and  occur  usually  with  dislocation  or 
other  severe  injury.  The  head  is  commonly  found 
split  or  starred,  and  the  lesion,  if 'limited  to  the 
head,  could  be  diagnosed  only  with  the  aid  of 
X-rays.  The  upper  epiphysis  of  the  radius  is 
entirely  within  the  limits  of  the  annular  liga- 
ment, and  could  scarcely  be  separated  in  a  simple 
lesion.  It  is  a  mere  disc  of  cartilage  joining 
the  shaft  at  the  age  of  17.  When  the  neck  is 
broken  the  upper  end  of  the  lower  fragment  is 
drawn  well  forwards  by  the  biceps  muscle. 

Resection  of  the  elbow  may  be  performed 
in  many  ways.  In  all  procedures  there  is  danger 
of  injuring  the  ulnar  nerve,  and  some  little 
difficulty  often  in  clearing  the  prominent  in- 
ternal epicondyle.  If  the  knife  be  kept  close  to 
the  bone,  no  vessel  of  any  magnitude  should  be 
divided.  The  muscles  most  disturbed  are  the  tri- 
ceps, anconeus,  supinator,  extensor  carpi  ulnaris. 


300  THE    UPPER    EXTREMITY 

extensor  carpi  radialis  brevior,  and  brachialis. 
It  is  most  important  to  preserve  the  periosteum 
over  the  olecranon,  and  the  external  lateral  ex- 
pansion of  the  triceps  tendon  to  the  deep  fascia 
of  the  forearm,  so  that  this  muscle  may  still 
act  as  an  extensor.  It  is  never  necessary  to 
divide  the  insertion  of  the  brachialis,  still  less 
of  the  biceps,  although  some  few  fibres  of  the 
former  muscle  may  be  separated  in  removing 
the  upper  surface  of  the  ulna.  By  the  sub- 
periosteal  method  the  periosteum  is  carefully 
peeled  off  from  all  the  parts  to  be  resected,  and 
is  preserved.  By  this  means  the  triceps  retains 
a  hold  upon  the  ulna,  and  the  restoration  of 
the  joint  is  more  complete.  The  functions  of 
the  joint  may  be  well  restored  after  resection, 
especially  when  performed  by  the  subperiosteal 
method ;  but  it  would  appear  that  after  no  method 
are  the  anatomical  details  of  the  joint  repro- 
duced. Thus,  in  a^  successful  case,  the  new  joint 
will  assume  the  bimalleolar  form,  and  will  re- 
semble the  ankle-  rather  than  the  elbow-joint.  The 
humerus  throws  out  two  malleoli  on  the  sites  of 
the  normal  condyles,  and  in  the  concavity  between 
them  the  ulna- and  radius  are  'received.  Between 
the  ulna  and  the  humerus  new  ligaments  form, 
and  a  new  annular  ligament  for  the  radius  is  also 
developed.  If,  on  the  other  hand,  ankylosis  is 
inevitable,  then  steps  must  be  taken  to  secure 
that  fixation  will  occur  at  the  most  suitable  angle. 
It  has  been  found  by  experience  that  an  ankylosed 
elbow-joint  is  most  useful  when  the  forearm  is  set 
to  the  arm  at  an  angle  of  about  60° — at  such  an^ 
angle  the  hand  can  be  brought  to  the  mouth. 

Position  of  the  main  nerves  at  the  elbow. 
— The  musculo-spiral  (radial)  is  found  in  front 
of  the  external  epicondyle,  under  cover  of  the 
brachio-radialis,  where  it  divides  into  posterior 
interosseus  and  radial  cutaneous  branch.  The 
median  is  situated  at  the  inner  border  of  the 
brachial  artery:  the  ulnar  lies  in  a  groove  behind 
the  internal  epicondyle  (see  p.  389). 


CHAPTER  XIV 
THE      FOREARM 

Surface  :i  11:1  torn v.  —  At  its  upper  half,  and 
especially  in  its  upper  third,  the  limb  is  much 
wider  in  its  transverse  than  in  its  antero-posterior 
diameter.  A  horizontal  section  through  this  part 
will  show  a  cut  surface  that  is  somewhat  oval 
in  outline,  and  is  at  the  same  time  flattened  in 
front  and  more  convex  behind.  This  outline  is 
best  seen  in  muscular  subjects,  and  depends  chiefly 
upon  the  development  of  the  lateral  masses  of 
muscle  that  descend  from  the  epicondyles.  In  the 
non-muscular,  the  limb,  even  in  its  highest  parts, 
tends  to  assume  a  rounded  rather  than  an  oval 
outline.  In  women  and  children,  also,  the  limb 
is  round,  owing  to  the  comparatively  slight  de- 
velopment of  the  lateral  muscular  masses,  and 
to  the  accumulation  of  fat  on  the  front  and 
back  of  the  limb.  The  posterior  surface  of  the 
forearm  in  a  vigorous  subject  presents  along  its 
outer  border  a  prominence  formed  by  the  brachio- 
radialis  and  the  two  radial  extensors,  which  become 
tendinous  below  the  centre  of  that  border.  On 
the  lower  third  of  this  edge  is  a  slight  eminence, 
directed  obliquely  downwards,  outwards,  and  for- 
wards, and  due  to  the  crossing  of  the  extensors 
of  the  thumb.  In  the  middle  of  the  posterior 
surface  is  another  elevation,  running  down  from 
the  outer  (lateral)  epicondyle,  and  formed  mainly 
by  the  extensor  communis.  To  the  inner  side  of 
this  eminence  is  a  groove,  well  seen  in  the  very 
muscular,  that  indicates  the  posterior  dorsal  border 
of  the  ulna.  The  ulna  is  subcutaneous  throughout 
its  entire  extent,  and  can  be  readily  examined.  The 
301 


302  THE  UPPER  EXTREMITY 

upper  half  of  the  radius  is  too  deeply  placed  to 
be  well  made  out,  but  the  lower  half  of  ihe  bone 
can  be  easily  felt  beneath  the  skin.  The  course  of 
the  radial  artery  is  represented  by  a  line  drawn 
from  the  outer  border  of  tjie  biceps  tendon  at  the 
bend  of  the  elbow  to  a  point  in  front  of  the  styloid 
process  of  the  radius.  The  pulse  is  felt  between 
the  styloid  process  and  the  tendon  of  the  flexor 
carpi  radiahs  where  the  artery  rests  on  the  distal 
extremity  of  the  radius.  The  middle  and  lower 
thirds  of  the  ulnar  artery  follow  a  line  from 
the  inner  epicondyle  to  the  radial  side  of  the 
pisiform  bone.  The  ulnar  nerve  corresponds  to 
the  whole  length  of  this  line.  The  upper  third 
of  the  artery  would  be  represented  by  a  line 
drawn  from  the  middle  of  the  bend  of  the  elbow 
to  meet  the  first  line  at  the  junction  of  the 
upper  and  middle  thirds  of  the  inner  medial 
border  of  the  forearm.  Such  a  line  would  be 
slightly  curved,  with  its  concavity  outwards.  The 
tendons,  etc.,  that  can  be  demonstrated  at  the 
lower  extremity  of  the  forearm  will  be  considered 
in  the  description  of  the  wrist. 

Vessels.— It  is  well  to  note  the  very  free  anas- 
tomoses that  exist  along  the  greater  part  of 
the  limb  between  the  ulnar  and  radial  arteries. 
This  fact  was  illustrated  by  a  case  under  my 
(F.  T.'s)  care  in  the  London  Hospital.  A  seafaring 
man  had  inflicted  upon  his  left  forearm  three 
deep  transverse  wounds  across  the  front  of  the 
limb  with  a  sharp  knife.  The  wounds  were  about 
1^  inches  apart.  The  radial  artery  was  divided  in 
each  of  the  wounds,  and  that  vessel,  therefore, 
presented  six  cut  ends.  It  would  appear  to  be 
sufficient  to  ligature  the  proximal  and  distal  ends 
of  the  wounded  vessel,  and  to  leave  the  two  iso- 
lated portions  of  the  artery,  each  about  1|  inches 
in  length,  alone.  Ligatures  were  applied  to  five 
of  the  divided  ends,  and  the  lower  end  of  the 
upper  isolated  piece  of  the  artery  was  left  untied, 
and  the  effect  watched.  During  the  course  of  the 
day,  when  the  man  had  rallied  from  the  profound 


xiv]  BONES  OF  FOREARM  303 

faintness  due  to  the  great  loss  of  blood  he  had 
experienced,  copious  bleeding  took  place  from  this 
single  unsecured  end  of  the  vessel,  and  it,  of 
course,  had  also  to  be  tied. 

There  is  a  singular  absence  of  large  blood- 
vessels or  nerves  along  the  posterior  (dorsal) 
aspect  of  the  forearm,  and  it  is  significant  that 
this  is  the  aspect  of  the  limb  most  exposed  to 
injury.  For  a  hand's-breadth  below  the  olecranon 
there  is  almost  an  entire  absence  of  superficial 
veins. 

The  median  nerve  passes  between  the  humeral 
and  ulnar  heads  of  the  pronator  teres.  At  the 
wrist  the  median  is  between  the  tendons  of  the 
flexor  carpi  radialis  and  flexor  digitorum  sub- 
limis;  it  lies  deep  to  the  tendon  of  the  palmaris 
longus,  which  serves  as  a  useful  guide  to  its 
position. 

Bones  oi  tlie  forearm. — Transverse  sections 
of  the  limb  at  various  levels  show  that  the 
radius  and  ulna  are  in  all  parts  nearer  to  the 
dorsal  than  to  the  volar  aspect  of  the  extremity 
(Figs.  67  and  68).  This  relation  is  the  more 
marked  the  higher  up  the  section.  The  two  bones 
are  nearest  to  the  centre  of  the  limb  about  the 
lower  or  distal  end  of  the  middle  third.  At 
the  upper  or  proximal  part  of  the  forearm  the 
muscles  are  found  mainly  at  the  sides  and  in 
front.  The  more  distal  the  section  the  less  will 
the  bones  Jbe  covered  at  the  sides,  and  the  more 
equally  will  the  soft  parts  be  distributed  about 
the  volar  and  dorsal  aspects  of  the  limb.  It 
will  be  noticed  that  where  one  bone  is  the  more 
substantial  the  other  is  the  more  slender,  as  near 
the  elbow  and  wrist;  and  that  it  is  about  the 
centre  of  the  limb  that  the  two  are  most  nearly  of 
equal  strength.  Tha  proximity  of  the  two  bones, 
and  especially  of  the  ulna,  to  the  dorsal  aspect 
of  the  limb  permits  them  to  be  easily  examined 
from  that  surface,  while  it  is  from  the  same  aspect 
that  resections  and  other  operations  upon  the 
bones  are  most  readily  performed.  It  will  be 


304 


THE  UPPER  EXTREMITY 


[CHAP, 


understood,  moreover,  that  in  compound  frac- 
tures, due  to  penetration  of  fragments,  the  wound 
is  more  usually  on  the  dorsal  aspect  of  the  limb. 

The  important  movements  of  pronation  and 
supination  take  place  between  these  bones,  and 
round  an  axis  corresponding  to  a  line  drawn 
through  the  head  of  the  radius,  the  distal  end 


PALMARIS  LONCL/S 
FLEX    SUB.  DIG. 


ULNAR  ART. 

ULNAR  /v. 


FLEX. CARP.  /?. 


FLEX.  CAfiP. 
ULNARIS 


FLEX.  PROF. 
DIGITORUM 


EXT  CARP.  RAD 
LONG/OR 


EXT.  CARP  RAD.  BREVIOR  \       EXT.  MINIMI   DIG. 

EXT.  COMM.  DIG. 
EXT.  OSS/5  &  EXT.SECUNDI  INTER.  POLL, 

Fig.  67. — Transverse   section  through   the   middle  of  the 
forearm.     (After  Branne.) 


of  the  ulna,  and  the  metacarpal  bone  of  the  ring- 
finger.  In  extreme  pronation  the  radius  crosses 
the  ulna  obliquely;  the  two  bones  are  almost 
in  contact  at  the  point  of  crossing;  the  lower 
fibres  of  the  interosseus  membrane  and  the  dorsal 
radio-ulnar  ligament  are  tight.  "The  chief  in- 
fluence in  checking  supination  is  not  to  be  found 
in  ligament  at  all,  but  in  the  contact  of  the 


xiv]  FRACTURES   OF  FOREARM  305 

posterior  edge  of  the  ulnar  notch  of  the  radius 
with  the  tendon  of  the  extensor  carpi  ulnaris, 
as  it  lies  in  the  groove  between  the  styloid 
process  and  the  round  head  of  the  ulna"  (Sir 
H.  Morris).  Of  the  two  movements,  supination  is 
the  more  powerful.  This  is  illustrated  in  many 
ways.  In  using  a  screw-driver  or  a  gimlet 
the  movements  of  pronation  and  supination  are 
conspicuously  involved,  but  the  main  force  is 
applied  during  supination.  It  is  significant  that 
the  thread  of  a  corkscrew  is  so  turned  that  it 
shall  be  inserted  by  supination  rather  than  by 
pronation. 

The  only  position  in  which  the  two  bones  are 
parallel  to  one  another  is  the  mid-position  be- 
tween pronation  and  supination.  It  is  in  this 
posture  only  that  the  interosseous  membrane  is 
uncoiled  throughout.  Hence  the  selection  of  this 
position  in  the  adjustment  of  most  fractures 
of  the  forearm.  The  interosseous  space  is  an 
irregular  ellipse,  a  little  larger  below  than  above. 
It  is  narrowest  in  full  pronation,  widest  in 
supination,  and  nearly  as  wide  in  the  mid- 
position. 

It  may  be  noted  that  the  oblique  radio-ulnar 
ligament  tends  to  resist  forces  that  would  drag 
the  radius .  away  from  the  humerus,  and  takes 
the  place  and  the  function  of  a  direct  ligament, 
passing  from  the  humerus  to  the  radius,  while 
the  interosseous  membrane,  from  the  obliquity 
of  its  fibres,  compels  the  ulna  to  share  in  the 
strain  put  upon  the  radius  when  that  bone  is 
forced  upwards,  as  in  resting  on,  or  pushing 
with,  the  palm. 

Fractures  of  the  forearm. — The  two  bones 
are  more  often  broken  together  than  is  either  the 
radius  or  the  ulna  alone.  The  radius,  when 
broken  alone,  is  usually  fractured  by  indirect 
violence,  since  it^  receives  more  or  less  entirely 
all  shocks  transmitted  from  the  hand.  The  ulna, 
on  the  contrary,  is  more  often  broken  by  direct 
violence,  it  being  the  more  superficial  and  exposed 


306  THE    UPPER    EXTREMITY  [CHAP. 

of  the  two  bones.  For  example,  in  raising  the 
arm  to  ward  off  a  blow  from  the  head,  the  ulna 
becomes  uppermost.  Among  the  ancient  Egyptians, 
who  were  much  given  to  a  game  of  cudgels,  frac- 
ture in  the  distal  part  of  the  ulna  was  very 
common,  as  we  know  from  the  investigations  of 
Elliot  Smith  and  Wood- Jones.  When  the  two  bones 
are  broken  together,  the  violence  may  be  direct  or 
indirect.  Malgaigne  reports  a  case  where  both 
bones  in  a  patient  were  broken  by  muscular  vio- 
lence when  he  was  shovelling  earth.  Here  the  bones 
probably  were  broken  between  the  two  opposed 
forces  represented  by  the  biceps  and  brachialis 
above  and  the  weight  of  the  loaded  shovel  in 
the  hand  below.  When  both  bones  are  broken 
and  the  fractures  are  oblique,  shortening  may  be 
produced  by  the  united  action  of  the  flexors  and 
extensors.  The  displacement  varies  greatly,  and 
depends  rather  upon  the  direction  of  the  violence 
than  upon  muscular  action.  Thus  Hamilton 
says  :  "  I  have  seen  the  fragments  deviate  slightly 
in  almost  every  direction."  If  union  be  delayed, 
the  delay  is  usually  in  the  radius,  since  it  is  the 
more  mobile  of  the  bones. 

When  the  radius  alone  is  broken  (1)  between 
the  insertions  of  the  t  biceps  and  pronator  teres, 
the  upper  fragment  is  flexed  by  the  biceps  and 
fully  supinated  by  that  muscle  and  the  supin- 
ator.  The  lower  fragment  will  be  pronated 
by  the  two  pronators,  and  drawn  in  towards 
the  ulna  by  means  of  these  muscles.  If  such 
a  fracture  be  put  up  with  the  hand  midway 
between  the  prone  and  supine  positions,  the 
following  ^  evils  result:  the  upper  fragment  is 
fully  supinated  by  the  muscles;  the  lower  frag- 
ment is  placed  in  the  mid-position  by  the  splints. 
It  follows  that  the  proper  axis  of  the  bone 
is  not  reproduced,  and  the  use  of  the  biceps 
and  supinator  as  supinators  is  entirely  lost. 
Thus  patients  so  treated  usually  recover  with 
great  loss  in  the  power  of  supination;  and,  to 
avoid  this  ill  result,  it  is  advised  to  put  the 


xiv]  FRACTURES   OF   FOREARM  307 

limb  up  in  full  supination,  so  that  the  two  frag- 
ments may  unite  in  their  proper  axis,  the  upper 
fragment  being  supinated  by  the  muscles,  the 
lower  by  the  splints.  (2)  When  the  fracture  is 
between  the  insertions  of  the  two  pronators,  the 
upper  fragment  may  be  carried  a  little  forwards 
by  the  biceps  and  pronator  teres,  and  drawn  to- 
wards the  ulna  by  the  latter  muscle.  The  lower 
fragment  will  be  adducted  to  the  ulna  by  the 
pronator  quadratus,  and  its  upper  end  will  be 
still  further  tilted  towards  that  bone  by  the 
action  of  the  brachio-radialis  ^upon  the  styloid 
process. 

When  the  ulna  alone  is  broken,  as,  for  example, 
about  its  middle,  the  proximal  fragment  may  be 
drawn  a  little  forwards  by  the  brachialis,  while 
the  lower  fragment  will  be  carried  towards  the 
radius  by  the  pronator  quadratus. 

The  displacement,  however,  in  all  cases  is  in- 
fluenced as  much  by  the  direction  of  the  violence 
as  by  the  action  of  muscles.  When  the  fragments, 
after  fracture  of  one  or  of  both  bones,  fall  in 
towards  one  another,  so  as  to  meet  across  the 
interosseous  space,  attempts  are  sometimes  made 
to  separate  the  broken  ends  and  to  preserve  the 
integrity  of  the  space  by  the  use  of  graduated 
pads.  These  pads,  however,  if  applied  with 
sufficient  force  to  separate  the  fragments,  will 
compress  one  or  both  of  the  arteries  of  the  limb, 
and  cause  great  distress,  resulting  in  a  peculiar 
condition  known  as  ischaemic  contraction,  due, 
it  is  believed,  to  the  compression  shutting  off  the 
blood  supply  to  the  muscles.  Subsequently  the 
muscles  undergo  contracture  and  atrophic  changes, 
thus  becoming  useless.  This  condition  may  be 
produced  in  any  group  of  muscles  if  a  severe 
and  continuous  pressure  be  applied  to  them,  such 
as  results  from  a  too  tight  application  of  bandages 
or  retention  of  the  elbow  or  knee  in  a  position 
of  extreme  flexion.  The  fact  that  the  bulk  of  the 
venous  blood  of  the  forearm  is  returned  by  surface 
veins  may  explain  the  ready  occurrence  of  severe 


308  THE   OTPEfc    EXTREMITY          [CHAP. 

oedema  in  the  limb  when  fractures  are  treated 
with  improperly  applied  splints  or  bandages. 
Since  the  arteries  also  can  be  readily  affected  by 
pressure,  it  follows  that  gangrene,  as  a  result 
of  improper  treatment,  is  more  common  after 
fracture  of  the  forearm  than  after  fracture  in 
any  other  part. 

Amputation  of  the  forearm. — In  amputa- 
tion of  the  forearm  by  double  transfixion  flaps, 
at  about  the  upper  part  of  the  middle  third,  the 
parts  would  be  cut  in  the  following  manner  (Fig. 
67)  :  On  the  face  of  the  anterior  or  volar  flap 
would  be  seen  from  without  inwards  the  brachio- 
radialis  (cut  the  whole  length  of  the  flap),  then 
the  flexor  sublimis  (cut  to  a  like  extent),  and, 
lastly,  the  flexor  carpi  ulnaris.  Between  the 
brachio-radialis  and  the  flexor  sublimis  the  divided 
end  of  the  pronator  teres  is  seen;  and  between 
the  flexor  sublimis  and  the  skin  would  lie  the 
flexor  carpi  radialis  and  the  palmaris  longus. 
The  latter  would  appear  as  a  tendon  at  the  inner 
border  of  the  flap.  In  the  angle  between  the  two 
flaps  would  be  found,  in  front  of  the  radius,  a 
little  of  the  flexor  longus  pollicis,  and  in  front 
of  the  ulna,  the  flexor  profundus,  the  latter  cut, 
much  the  longer.  Quite  close  to  the  radius,  and 
for  the  most  part  behind  it,  would  be  the  lowest 
part  of  the  supinator,  while  behind  the  ulna 
would  be  the  cut  fibres  of  the  proximal  end  of 
the  abductor  longus  pollicis  (extensor  ossis  meta- 
carpi  pollicis).  On  the  face  of  the  posterior  flap 
would  be  seen  from  without  inwards  the  extensor 
carpi  radialis  longus  and  brevis,  the  extensor 
communis,  the  extensor  of  the  little  finger,  and 
the  extensor  carpi  ulnaris.  The  radial  artery 
will  run  the  whole  length  of  the  anterior  or  volar 
flap,  and  be  cut  near  its  outer  or  lateral  border 
to  the  inner  or  medial  side  of  the  brachio-radialis. 
The  ulnar  artery  will  be  cut  shorter,  in  front 
of  the  bone,  and  between  the  flexor  sublimis  and 
flexor  profundus.  The  volar  interosseous  vessels 
will  be  divided  immediately  in  front  of  the 


XIV] 


AMPUTATION   OF  FOREARM 


309 


interosseous  membrane.  The  dorsal  interosseous 
vessels  will  be  cut  long,  and  will  be  found  between 
the  superficial  and  deep  muscles. 

Fig.  68  shows  the  relation  of  the  parts  as 
they  would  be  cut  in  a  circular  amputation  of 
the  forearm  in  its  distal  third. 


FLEX   SUB. DIG. 

PALMARIS  LONGUS 


MEDIAN  NERVE. 
FLEX. CARP.  HAD. 


FLEX. LONG. POL.  / 


EXT.  CARP.  PAD. 
LONQIOR 


FLEX.  PROF. 
OIQITORUM 


'ATOR 
QUADRATUS 


I    INTER.  fOLL. 
EXT  SECUNOI    INTER.  POLL. 


EXT.  INDICtS 
EXT.  WIN .  DIG. 


EXT  COM    DIG. 


Fig.  68. — Transverse   section    through   the  lower  third  of 
the  forearm.     (After  Uraune. 


CHAPTER   XV 
THE  WRIST  AND  HAND 

Surface  anatomy.  —  The  following  structures 
can  be  made  out  about  the  wrist :  Commencing 
at  the  radial  side,  the  lower  extremity  and  styloid 
process  of  the  radius  can  be  well  denned.  The 
bone  is  here  superficial  in  front  and  behind. 
The  styloid  process  lies  more  towards  the  volar 
aspect  than  does  the  corresponding  process  of 
the  ulna,  and  also  descends  about  |  an  inch 
more  towards  the  hand.  The  outer  or  lateral 
surface  of  the  radius  at  the  wrist  is  crossed  by 
the  tendons  of  the  abductor  longus  pollicis  and 
extensor  brevis  pollicis.  These  are  very  distinct 
when  the  thumb  is  abducted,  and  the  slit-like 
interval  between  the  two  can  be  felt.  About  the 
centre  of  the  volar  aspect  of  the  wrist  is  the  palm- 
aris  longus  tendon,  which  is  usually  the  most 
conspicuous  of  the  tendons  on  this  aspect  of 
the  joint.  It  will  be  found  absent  in  quite  10  per 
cent,  of  wrists  examined.  It  is  rendered  most 
prominent  when  the  wrist  is  a  little  flexed,  the 
fingers  and  thumbs  extended,  and  the  thenar  and 
hypothenar  eminences  as  much  approximated  as 

Eossible.  A  little  to  its  outer  side  is  the  larger  but 
jss  prominent  tendon  of  the  flexor  carpi  radialis. 
In  the  narrow  groove  between  these  two  tendons 
lies  the  median  nerve,  and  on  the  radial  side  of 
the  flexor  carpi  radialis  is  the  radial  artery.* 
The  venae  comites  surround  the  artery,  and  when 

*  Sometimes  the  superficial  volar  arises  higher  and  is  larger  than 
usual.  It  then  runs  by  the  side  of  the  radial  in  front  of  the  wrist,  and, 
giving  additional  volume  to  the  pulse,  has  been  .the  foundation  of  the 
so-called  "  double  pulse." 

310 


THE   WRIST  311 

distended  alter  the  character  of  the  pulse  (Hill). 
Towards  the  ulnar  border  of  the  wrist  the  flexor 
carpi  ulnaris  tendon  is  evident,  descending  to 
the  pisiform  bone.  It  is  rendered  most  distinct 
when  the  wrist  is  slightly  flexed  and  the  little 
finger  pressed  forcibly  into  the  palm.  In  the 
hollow  which  this  posture  produces  between  the 
last-named  tendon  and  the  palmaris  longus  lie 
the  flexor  sublimis  tendons,  and  just  to  the  radial 
side  of  the  flexor  carpi  ulnaris  the  pulsations  of 
the  ulnar  artery  can  be  felt.  Beneath  the  thin 
skin  on  the  volar  aspect  of  the  wrist  can  be  seen 
a  part  of  the  plexus  of  veins  which  end  in  the 
median  and  volar  ulnar  trunks.  •  The  ulnar  nerve 
grooves  the  radial  side  of  the  pisiform  bone. 

On  the  dorsum  of  the  wrist  the  following 
tendons  can  be  readily  distinguished  from  without 
inwards  (Fig.  70)  :  the  extensor  longus  pollicis  (ex- 
tensor secundi  internodii),  the  extensor  communis, 
and  the  extensor  carpi  ulnaris.  Of  these,  the  most 
prominent  is  the  first-named.  It  is  rendered 
most  distinct  when  the  thumb  is  forcibly  abducted 
and  extended.  The  tendon  leads  up  to  a  small 
but  prominent  bony  elevation  on  the  back  of 
the  radius,  that  marks  the  outer  border  of  the 
osseous  groove  for  its  reception.  This  tendon, 
when  it  reaches  the  radius,  points  to  the  centre 
of  the  dorsal  surface  of  that  bone,  and  also 
indicates  roughly  the  position  of  the  interval 
between  the  scaphoid  (navicular)  and  semilunar 
(lunate)  bones.  The  lower  end  of  the  ulna  is 
very  distinct.  When  the  hand  is  supine,  its 
styloid  process  is  exposed  at  the  medio-dorsal 
aspect  of  the  wrist  ^to  the  medial  side  of  the 
extensor  carpi  ulnaris.  In  pro-nation,  however, 
the  process  is  rendered  less  distinct,  while  the 
head  projects  prominently  on  the  dorsum  of  the 
wrist,  and  is  found  to  lie  between  the  tendons 
of  the  extensor  carpi  ulnaris  and  extensor  digiti 
quinti. 

Radio -carpal  joint  (wrist-joint).— The  tip  of 
the  styloid  process  of  the  ulna  corresponds  to  the 


312  THE    UPPER    EXTREMITY  [CHAP. 

line  of  the  wrist- joint,  and  a  knife  entered  below 
that  point  would  enter  the  articulation.  A  knife 
entered  horizontally  just  distal  to  the  tip  of 
the  styloid  process  of  the  radius  would  hit  the 
scaphoid  bone.  A  line  drawn  between  the  two 
styloid  processes  would  slope  downwards  and 
outwards;  its  two  extremities  would  represent 
the  extreme  inferior  limits  of  the  radio-carpal 
joint,  and  would  fairly  correspond  to  the  chord 
of  the  arc  formed  by  ^the  line  of  that  joint.  The 
line  between  the  styloid  processes  would  be  nearly 
|  an  inch  beyond  the  summit  of  the  arch  of  the 
wrist- joint. 

There  are  several  folds  in  the  skin  on  the 
volar  aspect  of  the  wrist;  of  these,  the  distal  is 
the  most  distinct.  It  is  a  little  convex  down- 
wards, precisely  crosses  the  neck  of  the  os 
magnum  (capitate  bone)  in  the  line  of  the  third 
metacarpal  bone  (Tillaux),  and  is  not  quite  f  of 
an  inch  distal  to  the  arch  ^of  the  wrist- joint. 
It  is  about  |  an  inch  proximal  to  the  carpo- 
metacarpal  joint,  and  indicates  very  fairly  the 
upper  border  of  the  transverse  carpal  (anterior 
annular)  ligament  (Fig.  73). 

Palmar  surface  of  the  hand. — The  palm  is  con- 
cave in  the  centre,  where  the  skin  is  adherent  to 
the  palmar  aponeurosis  or  fascia.  This  "hollow 
of  the  hand "  is  of  somewhat  triangular  out- 
line, .with  the  apex  upwards.  On  either  side  arc 
the  tnenar  and  hypothenar  eminences.  At  the 
proximal  end  of  the  former  eminence  a  bony 
projection  is  felt,  just  distal  and  medial  to  the 
radial  styloid  process,  which  is  formed  by  the 
tubercle  of  the  scaphoid  and  ridge  on  the  tra- 
pezium (multiangulum  majus)  (Fig.  73).  The 
interval  separating  these  two  processes  of  bone 
cannot  alwavs  be  made  out.  At  the  proximal 
extremity  of  the  hypothenar  eminence  is  the 
projection  of  the  pisiform  bone,  and  just  below 
it  the  unciform  (hamate  ^  process  can  be  identified. 
Distal  to  the  hollow  of  the  palm,  and  opposite 
the  clefts  between  the  four  fingers,  three  little 


xv]  PALMAR  SURFACE  OF  HAND  313 

elevations  are  seen,  especially  when  the  proximal 
phalanges  are  extended,  and  the  middle  and 
distal  are  flexed.  These  correspond  to  the  fatty 
tissue  between  the  flexor  tendons  and  the  digital 
slips  of  the  palmar  aponeurosis.  The  grooves 
which  separate  the  elevations  correspond  to  those 
slips. 

As  the  hand  is  closed,  certain  definite  creases 
or  folds  become  apparent  in  the  palm.  In  the 
palm  of  the  extended  hand  these  creases  are 
represented  by  lines  which  have  been  much  ex- 
ploited by  the  unscrupulous  at  the  expense  of 
the  credulous,  but  for  the  surgeon  they  are  mere 
surface  guides  to  deeper  structures.  Two  of  them 
(see  Fig.  69)  are  transverse  in  direction — the 
proximal  transverse  and  distal  transverse — both 
becoming  thrown  into  folds  as  the  fingers  are 
flexed  on  the  palm.  The  two  oblique  folds,  the 
radial  oblique  and  ulnar  oblique  (often  inter- 
rupted), are  apparent  when  the  thumb  is  opposed 
or  flexed  towards  the  fingers.  The  proximal 
transverse  fold  as  it  crosses  the  middle  of  the 
palm  marks  the  convexity  of  the  superficial  volar 
(palmar)  arch.  The  distal  transverse  fold  crosses 
the  necks  of  the  fifth,  fourth,  and  third  meta- 
carpals,  and  marks  approximately  the  beginnings 
of  the  mucous  or  synovial  sheaths  of  the  three 
digits  on  the  ulnar  side  of  the  hand.  It  is  at 
a  level  corresponding  to  the  distal  transverse  line 
that  the  palmar  aponeurosis  (fascia)  breaks  up 
into  its  four  slips,  and  midway  between  this  fold 
and  the  webs  of  the  fingers  lie  the  metacarpo- 
phalangeal  joints.  Of  the  three  transverse  lines 
on  the  flexor  aspect  of  the  fingers,  one,  the 
proximal,  is  placed  f  of  an  inch  beyond  (distal 
to)  the  metacarpo-phalangeal  joint,  being  single 
for  the  index  and  little  fingers,  but  double  for 
the  middle  and  ring.  The  middle  and  distal  lines 
of  the  fingers  are  interphalangeal  folds.  The 
intermediate  lines  are  double  for  all  the  fingers, 
and  are  exactly  opposite  the  proximal  inter- 
phalangeal joints  (Fig.  69).  The  distal  creases 


314 


THE    UPPER    EXTREMITY 


[CHAP. 


are  single,  and  are  placed  somewhat  proximal  to 
the  corresponding  joints.  There  are  two  single 
creases  on  the  thumb,  corresponding  to  the  two 


Fig.  69. — Surface  markings  on  the  palm  of  the  hand. 

The  thick  black  lines  represent  the  palmar  lines.    The  termination 

of  the  radial  and  ulnar  arteries  in  the  superficial  and  deep  volar 

(palmar)  arches  is  shown. 

joints,    the    proximal    crossing     the    metacarpo- 
phalangeal  articulation  obliquely.    The  superficial 


xv]  DORSAL  SURFACE  OF  HAND  315 

volar  arch  may  be  represented  by  a  curved  line 
across  the  palm,  starting  from  the  pisiform  bone 
and  running  in  a  line  with  the  palmar  border 
of  the  thumb  when  outstretched  at  right  angles 
with  the  index  finger.  The  deep  arch  is  J-J  an 
inch  nearer  the  wrist,  and  its  position  may  be 
accurately  marked  by  a  line  drawn  from  the 
base  of  the  fifth  metacarpal  to  the  base  of  the 
second,  two  easily  distinguished  points.  The  volar 
digital  arteries  bifurcate  about  \  an  inch  proximal 
to  the  clefts  between  the  fingers  (Fig.  69). 

Dorsal  surface  of  the  hand.  — On  the  radial  side 
of  the  wrist,  when  the  thumb  is  extended,  a  hollow 
is  obvious  between  the  abductor  longus  pollicis  and 
extensor  brevis  pollicis  and  the  extensor  longus 
pollicis.  French  writers  have  termed  this  hollow 
"tabatiere  anatomique "  (Fig.  70).  Across  this 
hollow  and  beneath  the  tendons  just  named  runs 
the  radial  artery.  Under  the  skin  over  the  space 
can  usually  be  seen  a  large  vein,  the  cephalic 
vein  of  the  thumb.  Across  the  space  also  runs 
the  lateral  division  of  the  terminal  branch  of  the 
cutaneous  radial  nerve.  .  In  the  floor  of  the  "  snuff- 
box "  are  the  scaphoid  bone  and  the  trapezium. 
The  extensor  longus  pollicis  crosses  the  apex  of 
the  first  interosseous  space.  The  sesamoid  bones  of 
the  thumb  and  the  joint  between  the  trapezium 
and  the  first  metacarpal  bone  can  all  be  well: 
made  out.  The  latter  articulation  is  situated  in 
the  floor  of  the  "tabatiere."  On  the  back  of  the 
hand  the  various  tendons  and  the  surface  veins, 
too,  can  all  be  clearly  distinguished.  Between 
the  first  and  second  metacarpal  bones  is  the  first 
dorsal  interosseous  muscle,  which  forms  a  con- 
spicuous prominence  when  the  thumb  is  pressed 
against  the  side  of  the  index  finger.  The  three 
rows  of  knuckles  are  formed  by  the  proximal  bones 
of  the  several  joints. 

The  skin  of  the  palm  and  of  the  front  of 
the  fingers  is  thick  and  dense,  while  that  on  the 
back  of  the  hand  is  much  finer.  The  palm, 
the  fronts  and  sides  of  the  fingers,  and  the 


316 


THE 


EXTREMITY 


[CHAP. 


dorsal    aspects   of    the    last    phalanges,    all    show 
entire    absence    of    hair    and    of    sebaceous 


an 


glands.  These  parts  are,  therefore,  exempt  from 
the  maladies  that  attack  hair-follicles  and  their 
gland  appendages.  On  the  dorsum  of  the  hand, 
and  of  the  proximal  and  middle  rows  of  phalanges, 
there  are  numerous  hairs  and  sebaceous  follicles. 


EXT.  PROP.  POLL. 
STYLOID  (RADIUS; 


ARTICULAR  (ULNA) 

STYLOID  (ULNA) 

SEMILUNAR 

CUNEIFORM 


BASE  OF  STH 
METACARP. 


Fig.  70.— Chief  surface  markings  on  the  dorsal  aspect  of 
the  wrist. 

Ext.  prop.  poll.  =  extensor  longus  pollicis  ;  scaphoid  =  nayicular  ; 

os  magnum  =  os  capitatum  ;  semilunar  =  os  lunatum  ;  cuneiform  = 

os  triquetrum. 

Sweat-glands  are  more  numerous  in  the  skin  of 
the  palm  than  in  any  other  part.  According  to 
Sappey  they  are  four  timqs  more  numerous  here 
than  they  are  elsewhere.  Krause  has  estimated 
that  nearly  2^800  of  these  glands  open  upon  a 
square  inch  of  the  palm.  Only  about  half  the 
number  are  found  upon  the  dorsum  of  the  hand. 


xv]        SUBCUTANEOUS   TISSUE   OF  HAND       317 

The  profuseness  with  which  the  palm  may  per- 
spire is  well  known,  and  is  very  marked  in  certain 
conditions.  The  cutaneous  nerve-supply  of  the 
hand  is  very  free.  The  nerves  present  Pacinian 
bodies,  which  are  far  more  numerous  in  the  hand 
than  in  any  other  part.  With  the  exception  of  the 
tip  of  the  tongue,  a  more  acute  degree  of  tactile 
sensibility  is  met  with  in  the  hand  than  elsewhere 
in  the  body.  The  most  sensitive  district  is  the 
palmar  surface  of  the  distal  or  ungual  phalanx 
of  the  index  finger,  while  the  least  sensitive  to 
tactile  impressions  is  the  dorsum  of  the  hand. 
It  may  be  said  that  the  tips  of  the  fingers  are 
about  thirty  times  more  acute  to  the  sense  of 
touch  than  is  the  skin  of  the  middle  of  the  fore- 
arm, which  is  among  the  least  sensitive  portions 
of  the  integument  as  regards  tactile  influences. 

The  subcutaneous  tissue  of  the  front  of  the 
hand,  and  especially  of  the  palm,  is  scanty  and 
dense,  and  somewhat  resembles  the  subcutaneous 
tissue  of  the  scalp  in  that  the  skin  is  closely  ad- 
herent to  it,  and  the  fat  it  contains  is  arranged 
in  minute  lobules  lodged  in  lacunae.  Cutaneous 
ligaments  bind  the  skin  down  at  the  creases  of 
the  palm  and  fingers.  The  subcutaneous  tissue 
on  the  dorsum,  however,  is  lax,  and  has  but  a 
frail  association  with  the  skin.  Thus  it  follows 
that  subcutaneous  extravasations  of  blood  are 
practically  impossible  in  the  palm  and  on  the 
anterior  aspect  of  the  fingers,  while  they  may  be 
very  extensive  on  the  dorsum.  In  like  manner 
oedema  of  the  extremity  is  conspicuously  marked 
upon  the  dorsal  surface,  while  the  palm  remains 
comparatively  free  even  in  severe  cases.  The 
denseness  of  the  integuments  of  the  palm  renders 
inflammation  of  ^  the  part  extremely  painful, 
owing  to  the  tension  that  is  so  readily  produced, 
whereas  inflammation  in  the  lax  tissues  of  the 
dorsum  may  reach  some  magnitude  without  caus- 
ing great  pain.  The  palm  of  the  hand  is  well 
adapted  to  meet  the  effects  of  pressure  and  fric- 
tion. The  cuticle  is  thick,  the  skin<  is  adherent, 


318  THE    UPPER    EXTREMITY  [CHAP. 

and  immediately  beneath  it  lies  the  dense  palmar 
aponeurosis,  which  efficiently  protects  the  palmar 
nerves  and  the  main  vessels;  while  it  must  be 
noted  that  the  front  of  the  hand,  and  especially 
the  palm,  is  singularly  free  from  surface  veins. 
Indeed,  the  great  bulk  of  the  blood  from  the  hand 
is  returned  by  the  superficial  veins  on  the  dorsa 
of  the  fingers  and  hand.  In  like  manner,  the 
lymphatics  of  the  palm,  which  form  a  rich  sub- 
cutaneous plexus,  join  the  large  efferent  lym- 
phatics on  the  dorsum  of  the  hand. 

The  form  of  the  nail  varies  somewhat  in 
different  individuals,  and,  according  to  certain 
authors,  there  are  special  types  of  nail  to  be 
met  with  in  some  constitutional  diseases.  By  tho 
Hippocratic  hand  is  meant  a  hand  the  tips  of  the 
fingers  of  which  are  clubbed  while  the  nails  are 
much  curved.  This  condition  would  appear  to  be 
due  to  impeded  circulation  by  retardation  in  the 
return  of  venous  blood,  and  perhaps  also  to  im- 
perfect oxygenation  of  that  blood.  It  is  most 
often  met  with  in  congenital  heart  disease,  in 
phthisis,  empyema,  chronic  lung  affections,  and 
certain  thoracic  aneurysms.  There  are  several 
forms  of  inflammation  affecting  the  matrix  of  the 
nail  and  the  soft  parts  immediately  around  it 
(onychia,  paronychia).  Such  inflammations  lead 
to  great  deformity  of  the  structure  itself.  When 
a  nail  is  thrown  off  by  suppuration  or  violence 
a  new  nail  is  produced,  provided  any  of  the 
deeper  epithelial  cells  are  left.  During  conval- 
escence from  certain  illnesses  (e.g.  scarlet  fever), 
a  transverse  groove  will  appear  across  all  the 
nails.  This  groove  indicates  the  portion  of  nail 
formed  during  the  illness,  and  by  watching  its 
movement  the  rate  of  growth  of  the  nail  can  be 
estimated.  The  nail  grows  at  the  average  rate  of 
aVml  of  an  inch  per  week;  if  the  hand  is  im- 
mobilized by  splints  the  rate  of  growth  is  retarded. 
(Head).  It  may  be  noted  that  each  digital  nerve 
gives  a  special  branch  of  large  size  to  the  pulp 
beneath  the  nail,  and  this  abundant  nerve  supply, 


xvj  THE   PALMAR    FASCIA  319 

combined  with  the  inexpansibility  of  the  part, 
explains  the  intense  pain  felt  when  a  foreign 
body  is  thrust  under  the  nail. 

Beneath  the  skin  of  the  palm  is  the  dense  palmar 
fascia  or  aponourosis.  This  fascia  gives  almost 
as  much  strength  to  the  hand  as  would  so  much 
bone,  while  its  unyielding  character,  its  com- 
parative freedom  from  vessels  and  nerves,  render 
it  well  suited  to  withstand  the  effects  of  pressure. 
The  fascia  gives  slips  to  each  finger;  each  slip 
sends  fibres  to  join  the  digital  sheaths  of  the 
tendons,  the  skin,  and  the  superficial  transverse 
ligament.  In  the  disease  known  as  Dupuytren's 
contraction  the  palmar  fascia,  and  especially  its 
digital  slips,  become  contracted.  One  or  more 
or  all  of  the  fingers  may  be  involved  in  the  con- 
traction. The  proximal  phalanx  is  drawn  or 
flexed  towards  the  palm,  and  later  the  second 
phalanx  becomes  bent,  even  causing  dislocation  of 
the  proximal  interphalangeal  joint  (Hutchinson). 
The  skin  is  drawn  in  towards  the  fascia,  since 
the  two  structures  are  normally  connected  with 
one  another.  Experiment  shows  that  by  dragging 
upon  the  fascia  the  proximal  phalanx  can  be 
readily  bent,  and  also,  but  with  less  ease,  the 
middle  phalanx.  The  middle  part  of  the  palmar 
fascia  represents  the  tendon  of  the  palmaris  longus 
in  the  hand. 

The  structures  of  the  palm  are  divided  into 
three  spaces  by  the  fascia  (Fig.  71).  Thus  the 
muscles  of  the  thenar  and  hypothenar  eminences 
are  both  enclosed  in  a  thin  fascia  proper  to  each. 
The  two  spaces  formed  by  these  membranes  are 
enclosed  in  all  directions,  and  are  capable,  though 
only  in  a  feeble  way,  of  limiting  suppuration 
when  it  commences  in  them.  Between  these  two 
spaces  is  a  third  space,  which  is  roofed  in  by 
the  palmar  fascia.  This  cavity  is  closed  in  at  the 
sides,  but  is  open  above  and  below.  Above  there 
is  a  free  opening  beneath  the  annular  ligament 
and  along  the  flexor  tendons  into  the  forearm, 
while  below  there  are  the  seven  passages  provided 


320  THE    UPPER    EXTREMITY  [CHAP. 

for  by  the  division  of  the  palmar  fascia.  Of  these 
seven  passages,  four,  .situate  at  tho  roots  of  the 
several  fingers,  give  passage  to  the  flexor  tendons, 
while  the  remaining  three  correspond  to  the  webs 
between  the  fingers,  and  give  passage  to  the  lum- 
bricales  and  the  digital  vessels  and  nerves.  When 
pus,  therefore,  forms  on  the  palm,  beneath  the 
palmar  fascia,  it  cannot  come  forward  through 


Fig.  71.— Horizontal  section  of  the  hand  through  the  middle 
of  the  thenar  and  hypothenar  eminences.  (TUlam:) 

a,  Metacarpal  bone  :  6,  first  dorsal  interosseous  ;  c,  palmari*  brevis  ; 
d,  abductor  quinti  digit!  ;  e,  flexor  brevis  min.  dig.  ;  /,  opponens 
min.dig. ;  </,  flexor  brevis  poll. ;  h,  abductor  brevis  poll.;  /,  opponens 
poll. ;  j,  adductor  poll. ;  A;,  flexor  long.  poll.  ;  I,  dorsal  interossei ; 
m,  palmar  interossei ;  n,  flexor  sublimis  ;  o,  flexor  proi'undus ; 
•»,  superflc.  volae  ;  q,  median  nerve,  and  (on  inner  side)  ulnar 
artery  and  nerve  ;  r,  deep  volar  arch  ;  1,  palmar  fascia  ;  2,  outer 
septum  ;  3  inner  septum  ;  4,  deep  fascia  of  palm. 

that  dense  membrane,  but  escapes  rather  along  the 
fingers  or  makes  its  way  up  into  the  forearm. 
So  rigid  is  the  resistance  offered  by  the  palmar 
fascia,  that  pent-up  pus  will  make  its  way  through 
the  interosseous  spaces  and  appear  on  the  dorsum 
of  the  hand,  rather  than  come  through  the  cover- 
ings of  the  palm. 

In  opening  a  palmar  abscess,  when  it  points 
above  the  wrist,  the  incision  should  be  in  the  long 


xv]  TENDONS   OF   THE   WRIST  321 

axis  of  the  forearm,  should  be  above  the  trans- 
verse carpal  (anterior  annular)  ligament,  and 
is  most  conveniently  made  a  little  to  the  ulnar 
side  of  the  palmaris  longus,  for  a  cut  in  this 
position  would  escape  both  the  ulnar  and  radial 
arteries  and  also  the  median  nerve. 

The  tendons  about  the  wrist  are  bound  down 
and  held  in  place  by  the  transverse  carpal  and 
dorsal  carpal  (annular)  ligaments.  So  dense  is 
the  transverse  carpal  ligament,  that  even  in  ex- 
tensive abscess  of  the  palm  reaching  into  the 
forearm,  and  in  severe  distension  of  the  synovia! 
sheaths  beneath  the  ligament,  it  remains  firm 
and  will  not  yield.  The  lower  border  of  the 
dorsal  carpal  ligament  corresponds  to  the  upper 
edge  of  the  transverse  carpal,  and  these  struc- 
tures together  act  the  part  of  the  leather  bracelet 
which  the  labourer  sometimes  wears  around  his 
wrist,  and  which,  in  fact,  takes  the  function  of 
an  additional  ligament. 

The  fibrous  sheaths  for  the  flexor  tendons  ex- 
tend from  the  metacarpo-phalangeal  joints  to  the 
proximal  ends  of  the  distal  phalanges.  The  pulp 
of  the  distal  or  ungual  phalanx,  therefore,  rests 
practically  upon  the  periosteum.  Opposite  the 
finger-joints  the  sheaths  are  lax  and  thin,  and 
spaces  may  occur  between  the  decussating  fibres 
of  the  sheaths,  through  which  the  synovial  mem- 
brane lining  the  sheath  may  protrude,  it  is,  I 
believe,  through  this  less  protected  part  of  the 
sheath  that  external  suppuration  often  finds  its 
way  into  the  interior  of  the  sheath.  The  sheaths 
in  the  rest  of  their  course  are  dense  and  rigid, 
and  when  cut  across  remain  wide  open  (Fig.  72). 
Thus,  after  the  division  of  the  sheath,  as  in 
amputation,  an  open  channel  is  left  leading  into 
the  palm  of  the  hand,  and  offering  the  greatest 
facility  for  the  spread  of  pus  into  that  part.  It 
is  this  rigidly  open  fibrous  sheath  that  probably 
may  explain  the  frequency  of  suppuration  in  the 
palm  after  amputation  of  a  part  of  a  finger. 

The  tendons  accurately  fill  the  fibrous  sheaths. 


322  THE    UPPER    EXTREMITY  [CHAP. 

A  gangliform  growth  on  the  tendon  as  it  enters 
the  sheath,  or  a  constriction  of  the  sheath  with  an 
inequality  in  the  tendon,  gives  rise  to  the  con- 
dition known  as  "  snap  "  finger.  Such  a  digit 
cannot  be  extended  by  will,  but  when  pushed  a 
little  way  "  springs  back  with  a  snap  like  the 
blade  of  a  pocket  knife  "  (Abbe).  "  Congenital 
contraction  "  of  the  little  finger  is  very  common 

PHALANX 
EXTENSOR   TENDON 

SHIN 


^^m^g^m^mgtc     SHEATH 

/VERVE 
DIGITAL  ARTERY    \     FLEXOR  PROFUNDUS 

FLEXOR  3U  SLIM  IS 

Fig.  72. — Horizontal  section  through  the  middle  of  the 
first  phalanx.     (After  Tillaux.} 

in  a  slight  degree.  In  pronounced  cases  the  prox- 
imal phalanx  is  hyperextended  and  the  middle 
flexed.  Lockwood  found  in  such  a  case  that  the 
condition  was  due  to  a  contraction  in  the  fibrous 
sheath  in  front  of  the  joint.  Contracted  finger 
following  whitlow  is  due  to  an  adhesion  of  the 
tendons  to  their  sheath.  Paralytic  contraction  of 
the  flexor  muscles  also  brings  about  permanent 
contracture  of  the  fingers. 


XV] 


THE   WRIST-JOINT 


323 


Synovia  I  sacs  and  sheaths.— There  are  two 
synovial  sacs  beneath  the  transverse  carpal  liga- 
ment for  the  flexor  tendons,  one  for  the  flexor 
longus  pollicis,  the  other  for  the  flexor  sublimis  and 
profundus  tendons  (Fig.  73).  The  former  extends 
up  into  the  forearm  for  about  1^  inches  above  the 
ligament,  and  follows  its  tendon  to  its  insertion 
in  the  last  phalanx  of  the  thumb.  The  latter  rises 


FLEXOR    DIGITORUM 

UNCIFORM 

PISIFORM 

WRIST  FOLDS 

STYLOID  PROCESS 


FLEX.  LONGUS  POLLICIS 

TRAPEZIUM 

ANT.  ANNULAR  LIGAMENT 
SCAPHOID 

LEXOR  CARP.  RAOIALIS 
STYLOID  PROCESS 


Fig.    73.— Anterior   annular    ligament    of    the    wrist,  and 
synovial  sheaths  of  the  wrist  and  hand. 

The  creases  of  the  hand  are  indicated  by  black  lines  ;  the  synovial 

sheaths   are   shown   in  red.    Ant.  annular  ligament  =  transverse 

carpal ;  uncit'orm  =  os  hamatum. 

about  It?  inches  above  the  transverse  ligament, 
and  ends  in  diverticula  for  the  four  fingers.  The 
process  for  the  little  finger  usually  extends  to  the 
insertion  of  the  flexor  profundus  tendon  in  the 
ungual  phalanx.  The  remaining  three  diverticula 
end  about  the  middle  of  the  corresponding  meta- 
carpal  bones.  The  synovial  sheaths  for  the  digital 


324  THE    UPPER    EXTREMITY  [CHAP. 

part  of  the  tendons  to  the  index,  middle,  and  ring 
fingers  end  above  about  the  neck  of  the  meta- 
carpal  bones,  and  are  thus  separated  by  about 
£-|  an  inch  from  the  great  synovial  (mucous) 
sac  beneath  the  transverse  carpal  ligament.  Thus 
there  is  an  open  channel  from  the  ends  of  the 
thumb  and  little  finger  to  a  point  in  the  forearm 
some  l£  inches  above  the  wrist.  The  arrangement 
explains  the  well-known  surgical  fact  that  ab- 
scesses of  the  thumb  and  little  finger  are  apt  to  be 
followed  by  abscesses  in  the  forearm,  while  such 
a  complication  is  not  usual  after  suppuration  in 
the  remaining  fingers.  The  synovial  sac  for  the 
flexor  tendons  is  narrowed  as  it  passes  beneath 
the  transverse  carpal  ligament,  and  thus  it  hap- 
pens that,  when  distended  with  fluid  or  with  pus, 
it  presents  an  hour-glass  outline,  the  waist  of 
the  hour-glass  corresponding  to  the  ligament.  The 
two  synovial  sacs  beneath  the  ligament  sometimes 
communicate  with  one  another.  The  tendon  of  the 
flexor  carpi  radialis  perforates  the  insertion  of 
the  transverse  carpal  ligament  to  the  trapezium; 
it  is  surrounded  by  a  synovial  sheath  (Fig.  73). 

In  one  form  of  whitlow,  that  form  where  the 
pus  occupies  the  synovial  sheaths  of  the  tendons 
on  the  fingers  (thecal  abscess),  the  suppuration 
can  often  be  seen  to  end  abruptly  where  the  sheath 
ends,  when  the  index,  middle,  or  ring  finger  is 
involved,  viz.  opposite  the  neck  of  the  corre- 
sponding metacarpal  bones.  In  another  form  of 
whitlow  (the  abscess  in  the  pulp  at  the  end  of  the 
finger)  the  periosteum  of  the  third  phalanx  is 
readily  attacked,  there  being  no  intervening  ten- 
don sheath  over  that  bone.  In  this  affection  the 
bone  often  necroses  and  comes  away,  but  it  is 
significant  to  note  that  it^is  very  seldom  that  the 
whole  of  the  phalanx  perishes.  The  upper  part, 
or  base,  of  the  bone  usually  remains  sound,  and  is 
probably  preserved  by  the  insertion  of  the  flexor 
prpfundus  tendon.  The  base  of  the  bone  is  an 
epiphysis  that  does  not  unite  to  the  shaft  until 
the  eighteenth  or  twentieth  year. 


xv]  SYNOVIAL  SACS   OF  WHIST  325 

The  tendons  do  not  lie  free  within  the  sac,  but 
are  bound  to  it  by  folds  of  synovial  (mucous) 
membrane  in  much  the  same  way  as  the  bowel  is 
bound  to  the  abdominal  parietes  by  its  mesentery. 
These  folds  may  be  ruptured  in  severe  sprains, 
when  the  nutrient  vessels  for  the  tendon,  which 
are  contained  in  them,  may  be  torn.  Rupture 
is  followed  by  effusion  into  the  sac.  These  folds 
are  almost  absent  within  the  digital  sheaths,  the 
slight  ligamenta  longa  and  brevia,  near  the 
phalangeal  insertions  of  the  tendons,  being  their 
sole  representatives.  Synovial  sacs  are  lined  by 
a  squamous  epithelium,  and  have  extremely  free 
communication  with  the  lymphatic  vessels  of  the 
part.  Hence  the  free  absorption  of  infective 
matter  from  such  cavities.  Hence,  too,  the  ease 
with  which  inflammatory  processes  can  spread 
along  the  sheaths,  leading  to  the  formation  of 
adhesions  between  them  and  the  contained  tendons. 
When  such  adhesions  are  formed  and  organized, 
the  tendons  become  fixed  and  the  fingers  grow 
stiff  and  worse  than  useless.  The  importance 
of  early  movements,  after  the  inflammation  has 
subsided,  will  be  apparent,  for  only  by  active 
and  passive  movements  of  the  wrist  and  fingers 
can  the  tendons  be  prevented  from  becoming 
closely  adherent  to  their  sheaths. 

Beneath  the  dorsal  carpal  ligament  there  are 
six  synovial  sheaths  for  tendons,  corresponding 
to  the  six  canals  formed  by  that  ligament. 
The  sheath  most  frequently  inflamed  is  that  for 
the  abductor  longus  pollicis  and  extensor  brevis 
pollicis.  It  runs  from  a  point  about  f  of  an  inch 
above  the  radial  styloid  process  to  the  first  carpo- 
metacarpal  joint.  The  other  sheaths  reach  above  to 
the  upper  border  of  the  dorsal  carpal  ligament,  that 
for  the  two  radial  extensors,  however,  beginning 
about  \  an  inch  above  the  ligament.  The  sheaths 
for  the  extensor  communis  and  the  extensor 
minimi  digiti  extend  distally  to  the  middle  of  the 
metacarpus;  that  for  the  extensor  indicis  barely 
reaches  the  metacarpus.  The  other  sheaths  follow 


326  THE    UPPER    EXTREMITY  [CHAP. 

the  tendons  to  their  insertions.  The  sy_novial  lin- 
ing and  folds  of  these  sheaths  are  injured  in 
Colles's  fracture  of  the  radius.  The  tendons  be- 
come adherent  and  fixed  to  their  sheaths  unless 
this  be  prevented  by  passive  movements  of  the 
tendons. 

Blood-vessels  and  lymphatics. — The  hand 
is  very  well  supplied  with  blood,  and  indeed  the 
finger  pulp  is  one  of  the  most  vascular  parts  in 
the  body.  Cases  are  recorded  where  the  tip  of 
the  finger  has  been  accidentally  cut  off,  and  has 
grown  again  to  the  limb  on  being  immediately 
reapplied.  The  position  of  the  palmar  arches 
has  been  pointed  out.  It  is  well  known  that 
haemorrhage  from  either  of  the  palmar  arches  can- 
not be  checked  by  ligature  of  the  radial  or  ulnar 
artery  alone,  on  account  of  the  connexion  of  the 
arches  with  those  vessels;  and  it  is  also  known 
that  simultaneous  ligation  of  the  two  vessels  may 
have  no  better  effect,  owing  to  the  anastomoses 
between  the  palmar  arches  and  the  interosseous 
vessels.  The  anastomosis  between  the  two  palmar 
arches  is  freely  established  both  by  the  main 
vessels  themselves  and  by  the  communion  that 
exists  between  the  digital  arteries  from  the 
superficial  arch  and  the  palmar  interosseous 
branches  from  the  deeper  vessels.  In  bleeding 
from  the  palm,  the  simultaneous  ligature  of 
the  radial  and  ulnar  arteries  may  also  entirely 
fail  in  those'  cases  where  the  arches  are  freely 
joined,  or  are  more  or  less  replaced  by  large  and 
abnormal  interosseous  vessels,  or  by  a  large 
"median  artery."  When  either  the  radial  or  the 
ulnar  part  of  the  arches  is  defective,  the  lack  is 
usually  supplied  by  the  other  vessel ;  and  it  is 
well  to  note  that  the  deficiency  is  most  common 
in  the  superficial  or  ulnar  arch.  Pressure  ap- 
plied to  the  palm  to  arrest  bleeding  is  apt  to  cause 
gangrene,  owing  to  the  rigidity  of  the  parts  and 
the  ease  with  which  considerable  pressure  can  be 
applied. 

The  radial  artery,  as  it  curves  round  the  back 


xv]          BONES   AND  JOINTS   OF   WRIST          327 

of  the  hand  to  reach  the  deeper  part  of  the  palm, 
is  in  close  contact  with  the  carpo-metacarpal 
joint  of  the  thumb  (Fig.  70).  This  fact  must  be 
borne  in  mind  in  amputation  of  the  entire  thumb, 
and  also  in  resection  of  the  first  metacarpal  bone. 
The  superficial  volar,  if  large,  may  bleed  seri- 
ously. It  adheres  to  the  surface  of  the  transverse 
carpal  ligament,  and  may  therefore  be  difficult 
to  pick  up  when  wounded. 

From  the  larger  size  and  great  number  of  the 
lymphatics  about  the  fingers  and  on  the  dorsum  of 
the  hand,  it  follows  that  lymphangitis  is  more 
common  after  wounds  of  those  parts  than  after 
wounds  of  the  palm. 

Bones  and  joints.— The  distal  radio-ulnar 
joint  is  supported  by  the  powerful  triangular 
fibro-cartilage  (articular  disc),  which  forms  the 
strongest  and  most  important  of  all  the  liga- 
mentous  connexions  between  the  two  bones.  The 
synovial  sheath  of  the  extensor  quinti  digiti 
sometimes  communicates  with  this  joint,  and  may 
therefore  be  involved  when  that  articulation  is 
diseased. 

The  strength  of  the  wrist-joint  depends  not  so 
much  upon  its  mechanical  outline  or  its  liga- 
ments as  upon  the  numerous  strong  tendons  that 
surround  it,  and  that  are  so  closely  bound  down 
to  the  bones  about  the  articulation.  Moreover, 
in  the  case  of  the  wrist  the  long  lever  does 
not  exist  on  the  distal  side  of  the  joint.  The 
volar  radio-carpal  is  the  strongest  ligament  of 
the  joint,  while  the  dorsal  is  the  weakest.  The 
former  structure  limits  extension,  and  the  latter 
flexion ;  and  in  connexion  with  this  arrangement 
it  is  interesting  to  note  that  injury  from  forced 
extension  is  more  common  than  from  forced 
flexion.  Thus,  when  a  man  falls  upon  the  hand, 
he  more  usually  falls  upon  the  palm  (forced  ex- 
tension) than  upon  the  dorsum  (forced  flexion). 
Owing  to  ^the  thinness  of  the  dorsal  ligament, 
together  with  the  more  superficial  position  of  the 
hinder  part  of  the  joint,  it  follows  that  the 


328  THE    UPPER    EXTREMITY  [CHAP. 

effusion  in  wrist-joint  disease  is  first  noticed  at 
the  back  of  the  hand. 

Movements  at  the  wrist  take  place  as  freely 
in  the  intercarpal  joint  (between  the  first  and 
second  row  of  carpal  bones)  as  in  the  radio-carpal 
joint  (Fig.  70).  The  axis  of  the  radio-carpal  joint 
is  such  that  in  flexion  the  palm  turns  towards  the 
ulnar  side  of  the  forearm;  while  in  flexion  at  the 
mid-carpal  joint  the  palm  moves  towards  the  radial 
side.  When  movement  takes  place  at  both  joints 
these  tendencies  are  balanced  and  pure  flexion 
is  produced.  The  tendon  of  the  extensor  carpi 
ulnaris  is  placed  anteriorly  to  the  axis  of  the 
mid-carpal  joint,  but  behind  the  radio-carpal,  and 
therefore  produces  flexion  in  one  joint  and  exten- 
sion in  the  other  (Ashdqwne).  The  muscles  which 
act  on  the  wrist  exemplify  the  various  parts  that 
muscles  play  in  producing  a  purposeful  move- 
ment. A  muscle  may  act  as  (1)  a  prime  mover,  (2) 
an  antagonist,  (3)  a  synergic  muscle,  (4)  a  fixation 
muscle.  For  instance,  when  the  fingers  are  flexed  : 
the  deep  and  superficial  flexors  are  the  prime 
movers;  the  antagonists  in  action  are  the  exten- 
sors of  the  fingers ;  the  flexors  of  the  fingers  would 
also  produce  flexion  at  the  wrist  were  not  the 
extensors  of  the  wrist  thrown  into  action  as  syn- 
ergic muscles;  when  the  extensors  of  the  finger's 
act,  the  flexors  of  the  wrist  contract;  in  flexing 
and  extending  the  fingers  the  wrist  can  be  ren- 
dered immovable  by  the  flexors  and  extensors  of 
the  carpus,  which  then  act  as  muscles  of  fixation. 
Thus  a  movement  which  appears  simple  results 
from  the  action  of  groups  of  muscles,  and  it  is 
this  complexity  which  makes  the  diagnosis  of 
nerve  lesions  from  a  study  of  the  action  of  mus- 
cles so  difficult.  What  has  been  said  of  the  muscles 
of  the  wrist  applies  equally  to  all  the  muscles  of 
the  body.  (See  Beevor's  Croonian  Lectures,  1903.) 

It  is  a  well-known  fact  that  the  wrist-joint 
has  to  be  in  an  extended  position  before  tho 
flexors  of  the  fingers  can  act  with  power;  if  the 
wrist  is  flexed  they  lose  the  power  to  grasp. 


xv]  MOVEMENTS   AT   WRIST  329 

This  must  be  remembered  in  all  cases  where  the 
wrist-joint  is  likely  to  become  stiff  or  ankylosed ; 
it  must  be  set  in  an  extended  (dorsiflexed) 
position. 

But  little  movement  is  allowed  in  the  carpo- 
metacarpal  joints  of  the  index,  middle,  and  ring 
fingers,  but  in  the  like  joints  of  the  thumb  and 
little  finger  movements  are  free,  and  their  pre- 
servation is  of  great  importance  to  the  general 
usefulness  of  the  hand.  The  glenoid  (volar  meta- 
carpo-phalangeal)  ligaments  in  front  of  the  three 
finger-joints  are  firmly  attached  to  the  distal  bone, 
and  but  loosely  to  the  proximal.  Thus  it  happens 
that  in  dislocation  of-  the  distal  bone  backwards, 
the  glenoid  ligament  is  carried  with  it,  and  offers 
a  great  obstacle  to  reduction.  In  flexing  the 
middle  and  distal  phalanges  alone,  it  will  be  seen 
that  the  proximal  phalanx  is  steadied  by  the 
extensor  tendon  as  a  preliminary  measure;  and 
in^  paralysis  of  the  extensors,  flexion  of  these  two 
joints  alone  is  not  possible. 

Very  few  persons  have  the  power  of  flexing 
the  distal  finger-joint  without  at  the  same  time 
bending  the  adjoining  middle  phalangeal ;  but 
in  certain  inflammatory  affections  about  the  last 
phalanges  the  terminal  joint  is  sometimes  seen 
to  be  fixed  in  a  flexed  posture  while  the  other 
finger-joints  are  straight.  In  "mallet"  finger 
the  distal  phalanx  is  fixed  in  a  flexed  position. 
The  condition  is  due  to  a  partial  or  complete 
rupture  of  the  extensor  tendon  of  the  finger, 
commonly  the  result  of  a  blow  over  the  terminal 
knuckles. 

Colles's  fracture. — This  name  is  given  to  a 
transverse  fracture  through  the  lower  end  of  the 
radius,  from  i  to  1  inch  above  the  wrist-joint 
(Fig.  74).  It  is  associated  with  a  certain  definite 
deformity,  and  is  always  the  result  of  indirect 
violence,  a  fall  upon  the  outstretched  hand.  There 
are  good  reasons  why  the  bone  should  break  in  this 
situation.  The  lower  end  of  the  radius  is  very 
cancellous,  while  the  shaft  contains  a  good  deal  of 
L* 


330 


THE    UPPER    EXTREMITY 


[CHAP. 


compact  bone.  At  about  f  of  an  inch  from  the 
articular  surface  these  two  parts  of  the  bone  meet, 
and  their  very  unequal  density  greatly  tends  tc 
localize  the  fracture  in  this  situation.  As  to  the 
mechanism  of  this  lesion,  many  different  opinions 
are  still  held,  and  a  vast  deal  has  been  written 
on  the  subject.  Prof.  Chiene's  account  of  this 
lesion  is  subjoined,  as  representing  with  admir- 
able clearness  the  views  most  generally  accepted 


FRACTURED  STYLOID 


FRACTURED  SCAPHOID 


Fig.  74. — Showing  the  situation  of  Colles's  fracture  of 
the  radius,  with  fracture  of  the  styloid  of  the  ulna. 
The  usual  position  of  a  fracture  of  the  scaphoid  is  also 
indicated. 

as  to  the  nature  of  the  injury.  The  deformity 
in  Colles's  fracture  is  entirely  due  to  the  dis- 
placement of  the  lower  fragment. 

"  The  displacement  is  a  triple  one  :  (a)  backwards,  as 
regards  the  antero-posterior  diameter  of  the  forearm  ;  (b) 
rotation  backwards  of  the  carpal  surface  on  the  transverse 
diameter  of  the  forearm  ;  (e)  rotation  through  the  arc  of  a 
circle,  the  centre  of  which  is  situated  at  the  ulnar  attachment 
of  the  triangular  ligament,  the  radius  of  the  circle  being  a 


xv]  COLLES'S   FRACTURE  331 

line  from  the  ulnar  attachment  of  the  triangular  ligament  to 
the  tip  of  the  styloid  process  of  the  radius." 

In  over  50  per  cent,  of  cases  the  styloid  process 
of  the  ulna  is  also  broken  by  the  force  transmitted 
to  it  through  the  triangular  nbro-cartilage  (Mor- 
ton). By  means  of  this  rotatory  displacement,  the 
tips  of  the  two  styloid  processes  come  to  occupy  the 
same  level,  or  the  radial  process  may  even  mount 
above  the  ulnar.  In  nearly  every  case  there  is 
some  penetration  of  the  fragments,  the  compact 
tissue  on  the  dorsal  aspect  of  the  upper  fragment 
being  driven  (by  a  continuation  of  the  force  that 
broke  the  bone)  into  the  cancellous  tissue  on  the 
palmar  aspect  of  the  lower  fragment.  It  is  only 
in  very  rare  instances  that  the  fragments  are  so 
separated  as  to  ride  the  one  over  the  other.  In 
such  cases  the  radio-ulnar  ligaments  are  probably 
ruptured,  and  the  wrist  ceases  to  present  the  typi- 
cal deformity  of  a  Colles  fracture.  In  studying 
the  radiographs  of  170  cases  diagnosed  as  Colles's 
fracture,  Dr.  R.  Morton  found  there  was  disloca- 
tion as  well  as  fracture  in  3  and  separation 
of  the  lower  radial  epiphysis  in  11  cases.  This 
cpiphysis  is  often  separated  by  accidental  vio- 
lence. It  joins  the  shaft  about  the  twentieth  year. 
Its  junction  with  the  shaft  is  represented  by  a 
nearly  horizontal  line,  and  the  epiphysis  includes 
the  facet  for  the  ulna  and  the  insertion  of  the 
brachio-radialis. 

Since  the  introduction  of  radiographic  methods 
of  examination,  it  has  been  found  that  many 
injuries,  formerly  regarded  as  mere  sprains,  are 
really  due  to  fracture  or  displacement  of  carpal 
bones  or  fracture  of  a  metacarpal. 

Fracture  of  the  scaphoid  (navicular) 
occurs  as  the  result  of  falls  on  the  outstretched 
palm,  or  by  direct  violence.  It  lies  in  the  floor 
of  the  "snuff-box,"  and  may  be  palpated  there. 
The  semilunar  (os  lunatum)  is  most  frequently 
displaced,  and  of  the  metacarpal  bones  the  fifth 
is  most  frequently  fractured. 


332  THE    UPPER    EXTREMITY  [CHAP. 

Dislocations.    1.  At  the  wrist-joint.— So  strong 

is  this  articulation,  for  the  reasons  above  given, 
that  carpo-radial  luxations  are  extremely  rare. 
For  the  same  reasons,  when  they  do  occur  they 
are  usually  complicated,  and  are  associated  with 
tearing  of  the  skin,  rupture  of  tendons,  injury 
to  the  synovial  sheath,  or  fractures  of  the  adjacent 
bones.  The  luxations  of  the  carpus  may  be  either 
backwards  or  forwards,  the  latter  being  ex- 
tremely rare. 

There  are  five  articular  synovial  cavities  con- 
nected with  the  carpus.  They  occur  in  the  fol- 
lowing situations :  (a)  Between  the  carpus  and 
forearm  bones :  it  may  communicate  with  the 
lower  radio-ulnar  cavity  through  the  triangular 
fibro-cartilage  (articular  disc) ;  (6)  between  the 
unciform  and  the  fourth  and  fifth  metacarpals ; 
(c)  between  the  metacarpal  of  the  thumb  arid 
trapezium;  (d)  between  all  the  carpal  bones  and 
extending  to  the  carpo-metacarp'al  joints  of  the 
second  and  third  digits;  (e)  between  the  pisiform! 
and  cuneiform  bones.  Hernial  protrusions  and 
gangliform  growths  from  these  synovial  mem- 
branes are  frequently  seen  on  the  dorsum  of  the 
carpus. 

2.  Dislocation  of  the  os  magnum  (os  capitatum). 
—In  forcible  flexion  of  the  hand,  the  os  magnum 
naturally  glides  backwards  and  projects  upon  the 
dorsum.    In  very  extreme  flexion  (as  in  falls  upon 
the  knuckles  and  dorsum  of  the  metacarpus),  this 
movement    of   the   bone   backwards   may   be    such 
as  to  lead  to  its  partial  dislocation,  the  luxation 
being  associated  with  some  rupture  of  ligaments. 
In  one  recorded  case  this  luxation  was  produced 
by  muscular  force.     The  patient,  while  in  labour, 
"seized   violently   the   edge   of  her   mattress,    and 
squeezed  it  forcibly."     Something  was  felt  to  give 
way  in  the  hand,  and  the  head  of  the  os  magnum 
was  found  to  be  dislocated  backwards. 

3.  Dislocations   at    the     metacarpo  -  phalangeal 
joint  of  the  thumb. — In  this  luxation  the  proxi- 
mal phalanx  is  usually  displaced  backwards,  and 


xv]  AMPUTATION   AT  WRIST  333 

the  lesion  is  of  interest  on  account  of  the  great 
difficulty  often  experienced  in  reducing  the  bone. 
Mr.  Jonathan  Hutchinson  has  investigated  several 
cases  and  found  that  reduction  is  prevented  by 
the  fibre-cartilaginous  plate  on  the  palmar  aspect 
of  the  joint.  The  plate  is  firmly  attached  to 
the  phalanx  and  is  dislocated  with  it.  When 
subcutaneously  divided  from  the  extensor  aspect 
of  the  thumb,  the  dislocation  may  be  reduced  with 
ease.  Another  factor  is  that  the  head  of  the 
metacarpal  becomes  button-holed  between  the  two 
heads  of  the  flexor  brevis  pollicis  and  held  there, 
because  the  injury  caused  by  the  dislocation  sets 
up  in  these  muscles  a  strong  reflex  contraction. 
Such  contraction  disappears  with  the  establish- 
ment of  a  general  or  local  anaesthesia. 

Avulsion  of  one  or  more  fingers  may  be 
effected  by  severe  violence.  In  such  cases  the 
finger  torn  off  usually  takes  with  it  some  or  all 
of  its  tendons.-  These  tendons  are  practically 
drawn  out  of  the  forearm,  and  may  be  of  con- 
siderable length.  Billroth  figures  a  case  where 
the  middle  finger  was  torn  out,  taking  with  it  the 
two  flexor  and  extensor  tendons  in  their  entire 
length.  When  one  tendon  only  is  torn  away 
with  the  finger,  it  is  usually  that  of  the  flexor 
profundus. 

Amputation  ait  the  wrist-joint  by  the  cir- 
cular method. — In  the  dorsal  wound  will  be  cut 
the  following  tendons :  the  extensores  longus, 
indicis,  communis,  quinti  digiti,  and  ulnaris,  the 
cutaneous  branches  of  the  radial  nerve,  and  the 
dorsal  branch  of  the  ulnar  nerve.  The  two  radial 
extensors  will  be  cut  short  in  the  radial  angle 
of  the  wound,  as  will  also  be  the  abductor  and 
extensor  longus  pollicis.  The  radial  artery  will  be 
divided  close  to  the  radius.  In  the  palmar  wound 
will  be  found  the  ulnar  artery,  the  superficialis 
volse,  the  ulnar  and  median  nerves,  the  opponens, 
flexor  brevis,  and  abductor  pollicis  in  part,  the 
flexor  brevis,  opponens,  and  abductor  minimi 
digiti  in  part  (the  bulk  of  the  opponens  being 


334  THE    UPPER    EXTREMITY 

left  behind  on  the  hand),  and  the  tendons  of  the 
flexor  sublimis  and  flexor  carpi  radialis.  The  ten- 
dons of  the  flexor  profundus  and  flexor  longus 
pollicis  are  usually  cut  short  close  to  the  bones. 

Amputation  of  the  thumb  at  the  carpo- 
metacarpal  joint  by  flaps. — In  the  palmar  flap 
will  be  cut  the  abductor,  the  short  and  long 
flexor,  the  opponens,  and  the  adductor  pollicis. 
The  extensores  ossis  and  brevis  will  be  cut  short 
in  the  posterior  angle  of  the  flap.  The  extensor 
longus  and  a  considerable  portion  of  the  abductor 
indicis  will  be  found  in  the  dorsal  flap.  The 
vessels  divided  will  be  the  two  dorsal  arteries 
of  the  thumb  and  the  princeps  pollicis.  There  is 
great  danger,  in  this  operation,  of  wounding 
the  radialis  indicis,  and  the  radial  artery  itself 
where  it  begins  to  dip  into  the  palm. 

Epiphyses  of  the  upper  limb.— The  epi- 
physes  about  the  elbow  join  the  shafts  of  their 
respective  bones  at  17  years  (except  the  tip  of  the 
internal  condyle,  which  joins  at  18).  The  epi- 
physes  at  the  shoulder  and  wrist  extremities  of 
the  bones  join  at  20.  The  nutrient  canals  of  the 
three  bones  run  towards  the  elbow.  The  nutrient 
artery  of  the  humerus  comes  from  the  brachial 
or  inferior  profunda,  those  of  the  radius  and 
ulna  from  the  anterior  interosseous. 


CHAPTER    XVI 

THE    NERVE    SUPPLY    OF   THE    UPPER 
EXTREMITY 

AT  various  points  in  the  preceding  chapters  we 
have  touched  on  the  surgical  relations  of  indi- 
vidual nerve-trunks  of  the  arm.  It  will  now  be 
of  great  advantage  to  survey  the  nerve  supply 
to  the  upper  extremity  as  a  whole,  in  order  to 
establish  the  general  anatomical  principles  which 
guide  the  surgeon  to  a  rational  diagnosis  and 
treatment  of  nerve  lesions.  Primarily  the  human 
body  is  arranged  segmentally,  one  anatomical 
segment  following  another  along  the  axis  of  the 
skull  and  spine;  and  each  segment  has  its  own 
primary  nerve  supply.  Seeing  that  the  limbs 
are  outgrowths  from  the  trunk,  we  are  prepared 
to  find  that  each  limb-bearing  segment  will  con- 
tribute to  the  nerve  supply  of  the  limb.  That 
is  so.  The  upper  extremity  arises  in  the  embryo 
from  the  fifth,  sixth,  seventh,  and  eighth  cervical 
.  and  first  dorsal  segments ;  hence  it  is  the  spinal 
nerves  of  these  segments  which  contribute  to  the 
formation  of  the  bradiial  plexus  (Fig.  75).  To 
recognize  the  orderly  distribution  of  those  seg- 
mental  nerves  we  must  place  the  limb  in  primitive 
or  embryonic  position,  with  the  extensor  or  dorsal 
aspect  uppermost,  the  radius  and  thumb  on  the 
anterior  or  preaxial  border  of  the  limb,  and  the 
ulna  and  little  finger  on  the  ppstaxial  border. 
When  a  limb  is  placed  in  this  position  (see 
Fig.  77,  B),  the  fifth,  sixth,  seventh,  and  eighth 
335 


336 


THE    UPPER    EXTREMITY 


[CHAP. 


cervical  and  first  dorsal  nerves  will  be  seen  to 
be  distributed  in  an  orderly  manner  from  the 
preaxial  and  postaxial  border  of  the  limb.  The 
central  nerve  of  the  plexus  (the  seventh)  supplies 
the  central  digits  of  the  hand ;  the  sixth  supplies 


OUTER  CORD 


^MUSCULO-SPIRAL 
NERVE. 

Fig.  75. — Showing  the  dorsal  preaxial  origin  of  the  musculo- 
spiral  (radial)  nerve,  and  the  ventral  post-axial  origin 
of  the  ulnar  nerve  from  the  brachial  plexus. 

the  preaxial  and  the  eighth  the  postaxial  borders 
of  the  hand.  The  fifth  cervical  and  first  dorsal 
supply  respectively  the  preaxial  and  postaxial 
borders  of  the  upper  arm  and  forearm.  These 
are  the  chief  segmental  nerves,  but,  as  will  be 


xvi]  NERVE   SUPPLY  337 

seen  from  Fig.  75,  the  fourth  cervical  and  second 
dorsal  spinal  nerves  also  contribute  strands  of 
varying  size.  In  a  brachial  plexus  of  the  pre- 
fixed type  the  fourth  cervical  makes  a  relatively 
large  contribution,  the  second  dorsal  takes  no 
share;  in  the  postfixed  type  the  opposite  is  the 
case.  There  is  a  degree  of  individual  variation 
in  the  spinal  distribution  of  half  a  nerve  segment 
or  more.  Further,  it  must  be  remembered  that 
the  segmental  distribution  is  not  confined  to  the 
skin,  but  affects  all  the  deep  structures  of  the 
limbs,  particularly  the  muscles. 

In  Fig.  75  are  represented  the  origins  of  the 
ulnar  and  musculo-spiral  (radial)  nerves  in 
order  to  emphasize  another  primary  differentiation 
of  nerves.  As  they  issue  from  the  intervertebral 
foramina,  the  spinal  nerves  which  go  to  the  limb 
become  divided  into  ventral  and  dorsal  divisions, 
the  ventral  for  distribution  in  the  flexor  aspect 
of  the  limb,  the  dorsal  in  the  extensor  aspect. 
It  will  be  seen  that  the  ulnar  nerve  arises  from 
the  ventral  division  of  the  eighth  cervical  and 
first  dorsal,  while  the  musculo-spiral  arises  from 
the  dorsal  division  of  all  five ;  but  the  contribution 
from  the  first  dorsal  is  usually  a  very  slight 
one.  It  will  be  seen  also  that  the  extensor  nerves 
tend  to  be  preaxial  in  origin,  the  flexor  nerves 
postaxial. 

Further,  it  is  important  to  remember  that 
a  muscle  is  never  dependent  on  a  single  spinal 
nerve;  a  muscular  branch  always  contains  fibres 
from  two  or  more  spinal  nerves.  Hence,  section 
of  a  single  spinal  nerve  will  produce  only 
a  partial,  never  a  complete,  paralysis  of  any 
single  muscle.  The  cell  centres  in  the  spinal 
cord  with  which  the  nerve  fibres  of  the  brachial 
plexus  are  connected  are  arranged  in  functional 
groups.  Most  muscles  are  complex  in  action,  are 
concerned  in  different  acts  or  movements,  and 
must  therefore  receive  fibres  from  several  cell 
centres,  and  hence  these  fibres  will  issue  from 
the  cord  by  several  spinal  nerves.  To  produce 


338  THE    UPPER    EXTREMITY  [CHAP. 

complete  paralysis  in  a  muscle,  all  the  spinal 
nerves  contributing  to  its  nerve  supply  must  be 
divided.  A  muscle  may  be  paralysed  as  regards 
one  function  and  still  remain  active  to  another 
(Colin  Mackenzie).  It  must  also  be  kept  in 
mind  that  a  muscle  is  not  only  supplied  with 
motor  or  efferent  fibres,  but  has  a  most  abundant 
supply  of  sensory  or  afferent  fibres.  By  these 
latter  fibres  we  recognize  deep  pressure  and 
degree  of  contraction  or  pain.  Afferent  fibres, 
which  arise  in  tendons,  ligaments,  joints,  and 
bone,  are  also  contained  in  the  muscular  branches 
of  nerves.  The  nerves  arising  in  all  of  these 
structures  subserve  the  function  of  deep  sensi- 
bility. Under  certain  disordered  conditions  the 
afferent  stimuli  conveyed  by  these  nerves  give 
rise  to  the  sensation  of  pain. 

The  nerves  of  superficial  or  cutaneous 
sensibility  commence  in  the  skin.  The  fibres  of 
the  cutaneous  nerves  fall  into  two  groups:  (1) 
fibres  which  serve  the  function  of  what  Head 
and  Sherren  term  protopathic  sensibility — fibres 
which  convey  painful  stimuli :  stimuli  resulting 
from  injury,  such  as  pin-prick,  etc.,  or  stimuli 
caused  by  bodies  which  are  much  above  or  below 
the  normal  temperature  of  the  skin ;  (2)  fibres 
which  serve  the  function  to  which  the  same 
observers  have  given  the  name  of  epicritic  sen- 
sibility.* These  latter  are  of  at  least  three 
kinds :  (a)  those  which  convey  stimuli  resulting 
from  touch  by  a  light  substance,  such  as  cotton- 
wool; (6)  those  which  convey  stimuli  from  objects 
heated  moderately  above  body-temperature;  (c) 
those  which  convey  stimuli  from  objects  of  a 
temperature  moderately  below  that  of  the  skin. 
When  a  cutaneous  nerve  to  the  hand  or,  to  a 
distal  part  of  the  arm  is  cut,  it  is  found  that 
the  area  losing  its  sensitiveness  to  pin-prick  is 
much  less  than  the  anatomical  distribution  of  the 
nerve,  while  the  loss  to  light  touch  approximately 
corresponds  fto  the  area  of  anatomical  distribution 

*  See  post,  p.  345. 


xvi]  LESIONS   OF  LIMB  NERVES  339 

(see  Fig.  78,  p.  345).  In  other  words,  in  the  distal 
parts  of  the  limb  there  is  a  great  degree  of 
overlapping  in  the  distribution  of  adjoining  proto- 
pathic  systems,  whilst  in  the  proximal  and  basal 
parts  of  a  limb  the  case  is  the  reverse,  the 
epicritic  system  having  the  greater  overlap.  It 
is  well  known  that  if  a  nerve  is  in  process  of 
repair  after  suture,  protopathic  sensibility  returns 
before  epicritic  in  the  area  of  normal  distri- 
bution. Further,  it  has  been  observed  that  in 
the  case  of  a  nerve  which  is  being  compressed 
against  a  cervical  rib,  or  within  a  healing  scar, 
the  area  of  protopathic  distribution  is  more 
reduced  or  contracted  than  that  of  epicritic  sen- 
sibility (Stop  ford). 

In  compression  and  other  lesions  of  limb  nerves, 
disturbance  of  the  vase-motor  system  is  of  ten 
observed.  The  vaso-motor  supply  to  the  arteries 
of  the  limbs  has  been  re-investigated  by  Prof. 
Wingate  Todd  and  his  pupils.  There  is  a  special 
branch  from  the  sympathetic  cord  of  the  neck, 
given  off  to  the  subclavian  artery  before  that 
vessel  reaches  the  first  rib.  The  median  and  ulnar 
in  their  course  down  the  arm  send  off  numerous 
branches  to  the  brachial  and  other  arteries.  These 
vaso-motor  fibres  run  in  the  trunks,  cords,  and 
nerves  of  the  brachial  plexus,  and  are  particularly 
liable  to  injury  when  subjected  to  pressure. 
Further,  it  must  be  remembered  that  the  sheaths 
of  nerves  are  strong  and  protect  the  contained 
nerve  fibres  from  all  ordinary  degrees  of  violence. 
The  sweat-glands,  so  numerous  on  the  fingers  and 
palm  of  the  hand,  have  also  a  special  nerve  supply 
from  the  sympathetic  system.  Those  for  the  sweat- 
glands  of  the  palm  are  conveyed  in  the  median 
nerve,  for  it  is  only  on  section  or  paralysis  of 
this  nerve  that  the  glands  of  the  hand  are  dis- 
turbed. Under  those  conditions  they  produce  a 
profuse  paralytic  secretion. 

The  symptoms  which  follow  a  lesion  to 
the  nerves  of  the  upper  limb  depend  on  the 
point  injured.  If  the  fifth  spinal  nerve  be  crushed 


340  THE    UPPER    EXTREMITY  [CHAP. 

between  its  origin  in  the  spinal  cord  and  its  exit 
from  the  intervertebral  foramen,  either  from  frac- 
ture or  caries  of  the  cervical  vertebrae,  the  injury 
is  followed  by  paralysis,  partial  or  complete,  of 
the  rhomboids,  spinati,  deltoid,  biceps,  brachialis, 
and  brachio-radialis,  but  strangely  enough  the 
lesion  is  not  accompanied  by  loss  of  sensation. 
Perhaps  the  fact  that  the  posterior  root  of  the 
fifth  cervical  nerve  is  very  small  may  assist  to 
explain  this  fact  (W.  Harris).  Injury  to  the 
spinal  cord  just  above  the  origin  of  the  eighth 
cervical  vertebra  will  leaye  the  skin  of  the  uinar 
half  of  the  arm  anaesthetic,  while  the  muscles  of 
the  fingers,  hand,  and  wrist,  and  some  of  those  at 
the  elbow  and  shoulder,  will  be  paralysed.  The 
fibres  for  the  innervation  of  the  various  groups 
of  arm  muscles  pass  out,  as  we  have  just  seen, 
in  quite  an  orderly  manner  by  the  fifth  cervical 
to  the  first  dorsal  nerve  from  corresponding 
segments  of  the  cord.  Those  for  the  abductors 
of  the  shoulder  pass  out  by  the  fifth ;  for  the 
adductors,  by  the  sixth  and  seventh;  for  the 
flexors  of  the  elbow,  by  the  fifth  and  sixth;  for 
the  extensors,  by  the  seventh  and  eighth ;  for  the 
extensors  of  the  wrist  and  fingers,  by  the  sixth 
and  seventh;  and  for  the  flexors,  by  the  eighth 
and  first  dorsal.  It  is  important  to  remember 
that  a  cervical  spinal  nerve  makes  its  exit  from 
the  canal  opposite  the  origin  of  the  next  spinal 
nerve. 

The  following  is  Dr.  Herringham's  account  of 
the  usual  spinal  origin  of  the  fibres  in  the 
nerves  of  the  upper  limb,  and  of  the  usual  supply 
of  the  chief  muscles : 


Nerves 


Long  thoracic,  5,  6,  7. 

Suprascapular,  5,  or  5,  6. 

External  (lateral)  cutaneous, 
5,  6,  7. 

Internal  (medial)  cutane- 
ous, 1,  or  8,  1. 


Lesser  internal  (medial)  cu- 
taneous, 1. 

Circumflex  (axillary),  5,  0. 

Median,  6,  7,  8,  1. 

Ulnar,  8,  1 . 

Musculo-spiral  (radial),  6,  7, 
8,  or  5,  6,  7,  8. 


XVI] 


NERVE  SUPPLY  OF  FINGERS 


341 


Muscles 


3,  4,  5,  Lev.  scap. 

5,  Rhomboids. 

5.  or  5,  6,  Biceps,  brachialis 
ant.,  supra-  and  infraspi- 
natus,  teres  minor. 

5, '6,  Deltoid,  subscapularis. 

(5,  Teres  major,  pronator 
teres,  flexor  carpi  rad., 
brachio-radialis  and  su- 
pinator,  superficial  thenar 
muscles. 

5,  6,  7,  Serratus  magnus. 


6  or  7,  Extensores  carpi  rad. 

7,  Coraco-brachialis,  latiss. 
dorsi,  extensors  at  back  of 
forearm,  outer  head  of 
triceps. 

7,  8,  Inner  head  of  triceps. 

7,  8,  1,  Flexor  sublimis,  flex- 
ores   profund.,  carpi  uln., 
long,  poll.,  pronator  quad. 

8,  Long-  head  of  triceps,  hy- 
po thenar  muscles,  interos- 
sei,  deep  thenar  muscles. 


In  the  cutaneous  nerve  supply  of  the 
fingers,  it  must  be  remembered  that  on  the 
palmar  aspect  the  thumb,  the  two  outer  fingers, 
and  the  radial  side  of  the  ring  finger  are 
supplied  by  the  median,  the  remaining  one  and 
a  half  fingers  by  the  ulnar  (Fig.  76).  On  the 
dorsal  aspect  the  thumb  is  supplied  by  the 
lateral  radial  cutaneous,  the  index  and  middle 
fingers  are  supplied  (as  far  as  the  base  of  the 
second  phalanx)  by  the  radial,  and  over  the 
second  and  third  phalanges  by  the  median.*  The 
little  finger  and  the  ulnar  side  of  the  ring-finger 
are  supplied  by  the  ulnar.  The  radial  side  of 
the  ring  finger,  as  far  as  the  base  of  the  second 
phalanx,  is  supplied  by  the  radial,  and  the  rest  of 
this  side  of  the  digit  by  the  median  (Fig.  77). 
The  cleft  between  the  middle  and  ring  fingers 
is  occasionally  supplied  by  the  ulnar,  or  partly 
by  the  ulnar  and  partly  by  the  radial.  (The 
roots  and  spinal  segments  to  which  these  nerves 
belong  may  be  ascertained  from  Figs.  76  and  77.) 
The  hand  is  mainly  supplied  by  the  seventh.  The 
neighbouring  spinal  nerves,  as  is  also  the  case 
with  ordinary  terminal  branches,  overlap  widely 
in  their  distribution.  The  area  of  anaesthesia 
is  always  less  than  the  area  of  anatomical  dis- 
tribution. The  nerves  along  the  ulnar  side  of 

*  It  will  be  noticed  that  the  extension  of  a  ventral  nerve  to  the  dorsal 
aspect  of  the  two  distal  phalanges  is  a  departure  from  the  general  rule. 


THE    UPPER    EXTREMITY  [CHAP. 


C.VH 


o 

Fig.  76.— A,  Distribution  of  the  individual  cutaneous 
nerves  to  the  skin  on  the  flexor  (volar)  aspect  of 
the  arm.  B,  Distribution  of  the  spinal  (segmental) 
nerves  on  the  same  aspect. 


xvi]  DISTRIBUTION   OF  NERVES  343 

C.IV 


cvin 


\io 


O.I 


cvn 


Fig.  77. — A,  Distribution  of  the  individual  cutaneous 
nerves  on  the  extensor  or  dorsal  aspect  of  the  arm. 
B,  Distribution  of  the  spinal  (segmental)  nerves  on 
the  same  aspect. 


344  THE    UPPER    EXTREMITY  [CHAP. 

the  arm  are  derived  from  cord  segments  which 
also  give  off  sympathetic  (sensory)  nerves  to  the 
heart;  in  angina  pectoris  the  heart  is  really  the 
cause  of  the  pain,  but  the  patient  feels  it  on,  and 
refers  it  to,  the  ulnar  border  of  the  left  arm. 

Paralysis  of  tlie  lower  trunk  of  the  bra- 
chial  plexus. — Mention  has  already  been  made 
of  a  partial  paralysis  of  the  arm  in  cases  where  a 
cervical  rib  is  present  (see  p.  184).  The  paralysis, 
which  usually  begins  to  appear  soon  after  adult 
life  is  reached,  and  oftener  in  women  than  in 
men,  is  due  to  the  pressure  of  the  lowest  trunk 
of  the  brachial  plexus  on  the  rib ;  hence  the 
distribution  of  the  ulnar  nerve  is  the  area  most 
affected  (Fig.  75).  Prof.  Wood-Jones  has  shown  that 
the  subclavian  groove  of  the  first  rib  is  caused  by 
the  lowest  trunk,  and  that  the  pressure  of  this 
nerve  is  sufficient  to  cause  bending  of  the  rib  in 
*  some  cases.  It  is  not,  therefore,  surprising  that 
cases  are  recorded  of  nerve  disturbance  in  the 
distribution  of  the  lowest  trunk  in  individuals 
in  whom  there  is  no  cervical  rib.  The  lowest 
trunk  evidently  contains  the  main  supply  of 
yaso-motor  nerves  to  the  limb,  for,  in  the  cases 
just  mentioned,  the  skin  is  often  red  and  swollen 
as  a  result  of  a  vaso-motor  paralysis. 

Paralysis  of  the  musculo-spiral  (radial) 
nerve. — The  origin  of  this  nerve  from  the  brachial 
plexus  is  shown  in  Fig.  75.  When  the  paralysis 
is  complete,  the  hand  is  flexed  and  hangs  flaccid 
("drop-wrist"),  and  neither  the  wrist  nor  the 
fingers  can  be  extended.  e  The  latter  are  bent 
and  cover  the  thumb,  which  is  also  flexed  and 
adducted.  When  attempts  are  made  to  extend 
the  fingers,  the  interossei  alone  act,  producing 
extension  of  the  two  distal  phalanges.  Supination 
is  impaired.  Extension  at  the  elbow  is  lost,  but 
there  is  practically  no  loss  of  sensation  unless 
the  nerve  is  cut  above  the  origin  of  its  cutaneous 
branches.  Section  of  the  radial  cutaneous  nerve 
in  the  upper  part  of  the  forearm  gives  no  loss 
of  sensation  (Head  and  Sherren). 


xvi] 


THE   MEDIAN  NERVE 


345 


Paralysis  of  the  median  nerve.— Flexion  of 
the  middle  phalanx  is  impossible  in  every  finger, 
as  is  also  a  lite  movement  of  the  distal  joint  of 
the  index  and  middle  fingers.  Flexion  of  the 
distal  phalanges  of  the  two  inner  digits  is 
possible,  the  inner  part  of  the  flexor  profundus 
being  supplied  by  the  ulnar  nerve.  Flexion  of 
the  proximal  phalanx  of  the  ring  and  of  the  little 
finger  and  extension  of  the  second  and  third  pha- 
langes of  all  the  fingers  can  still  be  performed  by 
the  inner  lumbricales  and  interossei.  The  thumb 
is  extended  and  adducted,  and  can  neither  be 
flexed  nor  opposed.  Bending  of  the  wrist  is  only 


A  B  C  D 

Fig.  78. — Results  of  section  of  the  ulnar  nerve  (A,  B),  and 
of  the  median  nerve  (C,  D).     (Head  and  Sherren.} 

Black :  Area  in  which  epicritio  and  protopathic  sensibilities  are  lost. 
Stippled:  Area  in  which  only  epicritic  sensibility  is  lost. 

possible  when  the  hand  is  forcibly  adducted  by 
means  of  the  flexor  carpi  ulnaris,  which  is  nut 
paralysed.  Pronation  is  lost. 

Section  of  the  median  or  ulnar  nerves 
at  the  wrist  does  not  give  rise  to  the  results 
which  one  would  expect  from  their  anatomical, 
distribution.  Such  lesions  have  been  investigated 
by  Head  and  Sherren.  After  section  of  the  ulnar 
nerve  in  the  forearm — taking  this  nerve  as  an 
example  to  explain  their  observations  on  nerves 
generally — they  found  that  epicritic  sensibility 
is  lost  over  the  area  of  anatomical  distribution 
(Fig.  78).  Over  this  area  the  patient  is  unable  to 


346  THE    UPPER    EXTREMITY 

distinguish  light  touch  (tested  by  cotton-wool)  and 
degrees  of  temperature  between  22°-40°  C.  In  a 
small  area  of  the  fifth  digit  (see  Fig.  78)  neither 

E  ricks  nor  very  cold  or  very  hot  things  can  be 
Bit;  in  this  area,  besides  epicritic  sensibility, 
there  is  also  lost  the  form  known  as  protopathic. 
But  everywhere  over  the  area  of  the  ulnar  nerve 
deep  pressure  is  felt;  deep  sensibility  remains 
because  the  nerves  which  subserve  it  arise  in  the 
forearm  and  reach  the  fingers  by  the  tendons. 
If  the  tendons  are  cut,  deep  sensibility  also  is 
lost.  The  effect  of  cutting  any  nerve  depends  on 
the  nature  of  the  fibres  it  contains;  a  nerve  may 
contain  epicritic  fibres  for  a  small  area  and  proto- 
pathic for  a  much  wider,  or  vice  versa. 

Paralysis  of  the  ulnar  nerve.— Ulnar  flexion 
and  adduction  of  the  hand^are  limited.  Com- 
plete flexion  of  the  two  inner  fingers  is  impossible. 
The  little  finger  can  scarcely  be  moved  at  all. 
The  action  of  the  interossei  and  two  inner  lum- 
bricales  is  lost.  The  patient  is  unable  to  adduct 
the  thumb. 

In  testing  for  paralysis  of  muscles  in  the  hand 
it  is  extremely  important  to  observe  closely  the 
muscles  which  flex,  extend,  abduct,  and  adduct 
the  thumb.  The  ulnar  border  of  the  metacarpal 
of  the  thumb  can  be  approximated  to  the  radial 
border  of  the  corresponding  bone  of  the  index 
finger  by  only  two  muscles — the  adductor  pollicis 
and  first  dorsal  interosseous.  These^are  paralysed 
when  the  ulnar  nerve  is  cut.  Their  action  may 
be  simulated  by  the  flexor  longus  pollicis,  brevis 
pollicis,  or  opponens  pollicis,  but  in  such  cases  it 
will  be  observed  that  it  is  not  the  ulnar  border 
but  the  flexor  surface  of  the  thumb  which  is  moved 
towards  the  metacarpal  bone  of  the  index  finger. 

The  nerve  supplying  the  humerus  is  the  mus- 
culo-cutaneous.  The  radius  and  ulna  are  sup- 
plied by  the  anterior  interosseous  of  the  median. 
It  may  be  taken  as  a  general  law  that  the  nerve 
supply  of  a  bone  is  the  same  as  that  of  the  muscles 
which  are  attached  to  it. 


PART   IV.— THE   ABDOMEN    AND 
THE    PELVIS 

CHAPTER  XVII 
THE     ABDOMEN 

THE    ABDOMINAL    PARIETES 

Surface  anatomy. — The  degree  of  prominence 
of  the  abdomen  varies  greatly.  The  protuber- 
ance of  the  belly  in  young  children  is  mainly 
due  to  the  relatively  large  size  of  the  liver, 
which  occupies  a  considerable  part  of  the  cavity 
in  early  life.  It  also  depends  upon  the  small 
size  of  the  pelvis,  which  ^  is  not  only  unable  to 
accommodate  any  abdominal  structure  (strictly 
so  called),-  but  can  scarcely  provide  room  for 
the  pelvic  organs  themselves.  Thus  in  infancy  the 
bladder  and  a  great  part  of  the  rectum  are  vir- 
tually abdominal  viscera.  After  long-continued 
distension,  as,  for  example,  after  pregnancy, 
ascites,  etc.,  the  abdomen  usually  remains  unduly 
prominent  and  pendulous. 

In  cases  of  great  emaciation  it  becomes  much 
sunken,  and  its  anterior  wall  appears  to  have 
collapsed.  This  change  is  most  conspicuous  about 
the  upper  part  of  the  region.  Here  the  anterior 
parietes  immediately  below  the  line  of  the  costal 
cartilages,  instead  of  being  in  the  same  plane  with 
the  anterior  thoracic  wall,  may  so  sink  in  as  to 
be  almost  at  right  angles  with  that  wall  on  the 
347 


34S  ABDOMEN  AND  PELVIS  [CHA*. 

oiie  hand,  and  with  the  lower  part  of  the  ab- 
dominal parietes  on  the  other.  In  such  cases  the 
abdominal  walls  just  below  the  thoracic  line  may 
appear  to  be  almost  vertical  when  the  patient  is 
in  the  recumbent  posture.  This  change  of  sur- 
face is  of  importance  in  gastrostomy,  since  the 
subjects  for  that  operation  are  usually  much 
emaciated,  and  the  incision  has  to  be  made  close 
below  the  costal  line. 

The  position  of  the  linea  alba  above  the  um- 
bilicus is  indicated  by  a  slight  median  groove, 
but  no  such  indication  exists  below  the  navel. 
The  linea  semilunaris,  which  corresponds  to  the 
lateral  or  outer  border  of  the  rectus  abdominis, 
may  be  represented  by  a  slightly  curved  lino 
drawn  from  about  the  tip  of  the  ninth  costal 
cartilage  to  the  pubic  spine  (tubercle).  Above 
the  umbilicus  the  line  is  indicated  on  the  surface 
by  a  shallow  depression.  The  outline  of  the 
rectus  can  be  well  seen  when  the  muscle  is  in 
action.  It  presents  three  "  linese  transversse  "- 
one  usually  opposite  the  xiphoid  process,  one 
opposite  the  umbilicus,  and  a  third  between  the 
two.  The  two  upper  of  these  lines  are  obvious 
in  well-developed  subjects. 

The  site  of  the  umbilicus  varies  with  the 
obesity  of  the  individual  and  the  laxity  of  the 
abdomen.  It  is  always  about  2  cm.  (|  of  an 
inch)  below  the  centre  of  the  line  between  the 
xiphoid  process  and  the  pubes.  In  the  adult  it 
is  some  way  above  the  centre  of  the  body,  as 
measured  from  head  to  foot,  while  in  the  foetus 
at  birth  it  is  below  that  point.  It  corresponds 
in  front  to  the  disc  between  the  third  and  fourth 
lumbar  vertebrae,  and  behind  to  the  tip  of  the 
third  lumbar  spinous  process.  It  is  situated 
about  f  of  an  inch  above  a  line  drawn  between  the 
highest  points  of  the  two  iliac  crests. 

The  anterior  superior  spine,  the  pubic  spine, 
and  the  inguinal  (Poupart's)  ligament  are  all 
conspicuous  and  important  landmarks.  The  pubic 
spine  is  nearly  in  the  same  horizontal  line  as 


xvii]  ABDOMINAL   PARIETES  349 

the  upper  edge  of  the  great  trochanter.  It  is 
very  distinct  in  thin  subjects.  In  the  obese 
it  is  entirely  lost  beneath  the  pubic  fat.  In 
such  individuals,  however,  it  can  be  detected, 
when  the  subject  is  a  male,  by  invaginating  the 
scrotum'  so  as  to  pass  the  finger  beneath  the  sub- 
cutaneous fat.  In  the  female  the  position  of 
the  process  may  be  made  out  by  abducting  the 
thigh  and  thus  making  prominent  the  tendon 
of  origin  of  the  adductor  longus  muscle.  This 
muscle  arises  from  the  body  of  the  pubes  im- 
mediately below  the  spine,  and  by  running  the 
finger  along  the  muscle  the  bony  prominence 
may  be  reached.  If  the  finger  be  placed  upon 
the  pubic  spine  it  may  be  said  that  a  hernia 
descending  to  the  inner  side  of  the  finger  will  be 
inguinal,  while  one  presenting  to  the  outer  side 
will  be  femoral.  In  the  erect  position  of  the  body 
the  anterior  superior  spine  is  a  little  below  the 
level  of  the  promontory  of  the  sacrum,  while  a 
point  taken  over  the  junction  of  sternum  and 
ensiform  process — the  sterno-ensiform  point — is 
opposite  the  upper  part  of  the  tenth  dorsal  ver- 
tebra. This  point  can  be  readily  recognized  in 
even  fat  subjects  by  the  depression  below  the 
sternal  insertions  of  the  seventh  pair  of  costal 
cartilages,  and,  as  will  be  seen  presently,  forms 
a  valuable  landmark.  A  point  taken  midway 
between  the  umbilicus  and  sterno-ensiform — the 
m  id = epigastric  point  —  lies  opposite  the  disc  be- 
tween the  first  and  second  lumbar  vertebrae  and 
is  a  surface-marking  of  great  clinical  utility 
(Addison). 

In  that  part  of  the  back  which  corresponds  to 
the  abdominal  region,  the  right  and  left  masses 
of  the  erector  spinse  are  distinct,  and  in  any 
but  fat  subjects  their  outer  edges  can  be  well 
defined.  Between  these  masses  is  the  spinal 
furrow,  which  ends  below  in  an  angle  formed 
by  the  two  great  gluteal  muscles.  Immediately 
behind  the  middle  of  the  crest  of  the  ilium  is  the 
supra-iliac  (Petit's)  triangle,  or  the  gap  between 


350  ABDOMEN  AND  PELVIS  [CHAP. 

the  external  oblique  and  latissimus  dorsi  muscles. 
The  fourth  lumbar  spine  is  about  on  a  level  with 
the  highest  part  of  the  iliac  crest.  In  counting 
the  ribs  it  is  well  to  commence  from  above,  since 
the  last  rib  may  not  project  beyond  the  outer 
edge  of  the  erector  spinse,  and  may  consequently 
be  overlooked. 

The  aorta  bifurcates  opposite  the  middle  of  the 
body  of  the  fourth  lumbar  vertebra,  just  to  the 
left  of  the  middle  line,  about  f  of  an  inch  below 
and  to  the  left  of  the  umbilicus.  A  line  drawn 
on  either  side  from  the  point  of  bifurcation  to 
the  middle  of  Poupart's  ligament  will  correspond 
to  the  course  of  the  common  and  external  iliac 
arteries.  The  first  two  inches  of  this  line  would 
cover  the  common  iliac,  and  the  remainder  the 
external. 

The  coeliac  axis  comes  off  opposite  the  lower 
part  of  the  twelfth  dorsal  vertebra,  at  a  spot 
about  Irr  inches  above  the  mid-epigastric  point, 
corresponding  behind  to  the  twelfth  dorsal  spine. 
The  superior  mesenteric  and  suprarenal  arte- 
ries are  just  below  the  axis.  The  renal  vessels 
arise  about  ^  an  inch  below  the  superior  mes- 
enteric, opposite  the  mid-epigastric  point.  The 
inferior  mesenteric  artery  comes  off  from  the 
aorta  about  1  inch  above  the  umbilicus.  The  deep 
epigastric  artery  follows  a  line  drawn  from  the 
middle  of  the  inguinal  ligament  to  the  umbilicus. 
Along  the  same  line  may  sometimes  be  seen  the 
superficial  epigastric  vein. 

The  abdominal  "  rings  "  will  be  referred  to 
under  Hernia  (p.  365  et  seq.). 

ANTERIOR  ABDOMINAL  PARIETES 
The  skin  over  the  front  of  the  abdomen  is  loosely 
attached  in  the  region  of  the  groin.  It  is  more  adher- 
ent to  the  deeper  parts  in  the  middle  line  than  else- 
where, but  not  so  adherent  as  to  hinder  the  spread 
of  inflammation  from  one  side  of  the  abdomen  to 
the  other.  In  cases  of  great  obesity  two  transverse 
creases  form  across  the  belly,  one  crossing  the 


xvn]  FRONT   OF   ABDOMEN  351 

umbilicus  and  the  other  passing  just  above  the 
pubes.  In  the  former  of  the  two  creases  the  navel 
is  usually  hidden  from  sight.  In  cases  of  anky- 
losed  hip-joint  transverse  creases  are  often  noted 
running  across  the  middle  of  the  belly.  They  are 
produced  by  the  freer  bending  of  the  spine  that 
is  usually  required  in  such  cases,  some  of  the 
simpler  movements  of  the  hip-joint  being  trans- 
ferred to  the  column  when  the  articulation  is 
rendered  useless. 

After  the  skin  has  been  stretched,  from  any 
gross  distension  of  the  abdomen,  certain  silvery 
streaks  appear  in  the  integument  over  its  lower 
part.  They  are  due  to  an  atrophy  of  the  skin 
produced  by  the  stretching,  and  their  position 
serves  to  indicate  the  parts  of  the  parietes  upon 
which  distending  forces  within  the  abdomen  act 
most  vigorously.  They  are  well  seen  after  preg- 
nancy, ascites,  ovarian  tumours,  etc. 

Beneath  the  skin  is  the  superficial  fascia, 
which  over  the  lower  half  of  the  abdomen  can  be 
readily  divided  into  two  layers^  The  great  bulk  of 
the  subcutaneous  fat  of  this  region  is  lodged  in  the 
more  superficial  of  the  two  layers.  In  cases  of 
great  obesity  the  accumulation  of  fat  is  perhaps 
more  marked  beneath  the  skin  of  the  abdomen 
than  it  is  elsewhere.  A  layer  of  fat  6  inches  in 
depth  has  been  found  in  this  region  in  cases  of 
great  corpulence.  The  superficial  vessels  and  nerves 
lie  for  the  most  part  between  the  two  layers  of  the 
fascia,  so  that  in  obese  subjects  incisions  may  be 
made  over  the  abdomen  to  the  depth  of  an  inch 
or  so  without  encountering  blood-vessels  of  any 
magnitude. 

The  deep  layer  of  the  superficial  fascia  con- 
tains elastic  fibres,  and  corresponds  to  the  tunica 
abdominalis  or  "abdominal  belt"  of  animals.  It 
is  attached  to  the  deeper  parts  along  the  middle 
line  as  far  as  the  symphysis,  and  to  the  fascia 
lata  just  beyond  the  inguinal  ligament.  In  the 
interval  between  the  symphysis  and  the  pubic  spine 
it  has  no  attachment,  but  passes  down  into  the 


352  ABDOMEN   AM)   I'KLVIS 

scrotum  and  becomes  the  dartos  tissue.  Extrava- 
sated  urine  that  li;is  reached  the  scrotum  may 
mount  up  on  to  the  abdomen  through  this  in- 
terval, and  will  Mini  In-  limited  l>y  the  deeper 
layer  of  the.  fascia.  It  will  not  be  able  to  pass 
down  into  the  thigh  on  account  of  the  attachment* 
of  the  fascia,  nor.  for  a  like  reason,  will  it  tend 
to  pass  over  the  middle  line.  In  the  same,  way 

eliiph\  scinalons  collections  following  injuries  to 
Mie  Chest,  \\lien  lieneaMl  tin-  deeper  layer  of  the 
fascia,  receive  a  cheek  at  the  groin,  and  lipomata 
also  that  grow  beneath  the  membrane  tend  to  be 
limited  by  the  middle  line  and  that  of  1'oupart's 
ligament. 

The  anterior  abdominal  parieles  vary  in  fhirk- 
IM'KS  in  different  subjects.  In  cases  of  great 
emaciation  the  outlines  of  some  of  the  viscera  may 
he  readily  made  out  or  even  seen  through  the 
thinned  wall.  In  some  cases  of  chronic  intestinal 
obstruction  the  outlines  of  the  distended  intestine 
are  visible,  and  their  movements  can  be  watched ; 
in  instances  of  obstruction  of  the  pylorus  the 
movements  of  the  dilated  and  hypertrpphied 
stomach  can  often  be  seen.  The  relative  thickness 
of  tho  abdominal  wall  in  various  subjects  depends 
rather  upon  the  amount  of  the  subcutaneous  fat 
than  upon  the  thickness  of  the  muscles.  This 
muscular  boundary  affords  an  admirable  protec- 
tion to  the  viscera  within.  By  contracting  the 
abdominal  muscles  the  front  of  the  belly  ran  be 
made  as  hard  as  a  board,  and  in  acute  peritonitis 
(his  contraction  can  sometimes  he  seen  to  pro 
duce  a  remarkahle  decree  of  rigidity.  A  blow 
upon  the  abdomen  when  the  muscles  are  firmly 
contracted  will  probably  do  no  injury  to  the 
viscera,  unless  the  violence  hr  extreme.  The  rigid 
muscular  wall  acts  with  the  ellicacy  of  a,  dense 
indiarubber  plate.  It  may  be  bruised  or  torn, 
but  it  will  itself  receive  the  main  shock  of  the 
contusion. 

Tho   probable   effect  on   the   contained   viscera 
of  a  blow  upon  the  abdomen  will  depend  upon 


KKONT    <>!«'    AHDOMKN  tt.H 

many  factors;  hut,  so  far  as  the  walU  themselves 

are  concerned,  Mm  effect  greatly  depends  upon 
whether  tho  blow  was  anticipated  or  not,  and 
upon  ill,-  extent  of  Mi.-  paddinr.  of  fat  that  18  fur- 

nished   to  tin-   paneles.       It"  tin-  blow   he  a  nt  in  pa  t  ed 

i IK     muscles   of   the   holly    will    be   instinctively 

cont  racled,  and  the  viscera  at,  once  provided 
with  a  linn  luii  elastic  shield.  Thus  the  abdo- 

minal  muscles  have  been  found  bruised  and  torn 
\\hile  tho  viscera  were  intact;  and,  on  the  other 
handt  in  oases  probably  where  the  muscles  were 

inert  or  taken  unawares,  a  viseus  has  been  found 
to  l>e  damaged  without  there  benny,  any  eon 

spicuous  lesion  in  the  belly-wall.    In  the  Great 

War      several      eases      were      recorded      of      j-.nn  ,h..i 
injury    to   a  luloin  i  na  1    \ist-era    and    \rt     llir    track    of 
the    bnllel     which    caused     the     \isceral     iii|'ii\      \\  •' 
eonlined    to    the    innsenlar    parictes.       l»c',idc-,    pro 
I  eel  i  us.1,'    i  he    \-i'.ccra,    the    iniiscnlar    \\all    seTVOS    as 
I  hiv  chief  mean  .  o|    \isci-ral  support.      The  nioinenl 
the     nprii'.lil     po-anre     i-,     a  .-aimed,     |  he     mii'.cle-,    of 
the     abdominal     \\all     pa          rdlexly     into     a     stale 
of    con  I  ract  ion ,     thus    bearing     the     \\eii-.ht     of    the 
abdomi  nal    contents. 

Alon:-,  (he  Mm  :i  :ill»:i  the  abdominal  wall  is 
thin,  tlen.se,  and  t  rci%  I  roni  \i  able  blood  vessel.*. 
llencc  in  main  operation  ,  upon  (lie  abdominal 
cavity  (he  incision  is  made  in  (he  middle  line. 

AlonK  the  outer  border  of  tho  reotus  muscle  (i.e. 

about    and    just    be\ond    the    linea    sem  1 1  n  n  a  r  is)    the 
paru'tes   al-.o   are    thin    and    lacking   in   VOSSelS)   and 

<•'  >n  ,e(  pien  t  I  \'    that     situation     is    \\cll    Milled     for    an 
incision.        Vhoilt    1     inch    below     the    na\el    the    two 

rooti   muscles  are  almost  in  contact*   and   here 

the  linea  alba  can  scarcely  be  said  to  <-\ist, 
\\hile  abo\e  the  mnselcs  remain  apart,  the  linea 
alba  being  normally  ,:  of  an  inch  wide.  In  prev; 
nancy,  obesity,  and  a".cil«*s  the  supra  Minbilica.l 
I'arl  ma\  become  '  01  more  inches  \\  ide,  but 
lh.>  narro\\  i  n  f  ra  nmbi  I  ica  I  part  i-,  n  naffecl  cd  ; 

\\iien  this  part  of  tho  linea  alba  widens  the  con- 

ilil  ion     is     kno\\n     as     ,//  rat  -n-titum     <>f     tht      r«-f/. 
M 


354  ABDOMEN  AND  PELVIS  [CHAP. 

In  this  case  the  contents  of  the  abdomen  bulge 
out  between  the  recti  when  these  two  muscles  are 
thrown  into  action,  as  when  a  patient  attempts  to 
assume  the  sitting  from  a  supine  posture  unaided 
by  the  arms.  Pellets  of  subperitoneal  fat  may 
grow  through  interstices  in  the  linea  alba  and 
give  rise  to  what  are  called  "fatty  herniae." 

The  fibrous  ring  of  the  umbilicus  is  derived 
from  the  linea  alba.  To  this  ring  the  adjacent 
structures — skin,  fascia,  and  peritoneum — are  all 
closely  adherent.  The  adhesion  is  such,  and  the 
amount  of  tissue  between  the  skin  and  peritoneum 
is  so  scanty,  that  in  operating  upon  an  umbilical 
hernia  it  is  scarcely  possible  to  avoid  opening 
the  sac. 

The  umbilicus  represents  the  point  where  the 
lateral  abdominal  walls  finally  close.  At  the 
sixth  week  the  opening  is  funnel-shaped  and  con- 
tains the  yolk-sac  and  a  fold  of  the  bowel  t9  which 
it  is  attached.  This  condition  may  persist  and 
give  rise  to  a  congenital  umbilical  hernia.  In 
the  foatus  three  vessels  enter  at  the  navel,  and 
immediately  separate  on  reaching  the  abdominal 
cavity,  the  vein  passing  directly  upwards  and  the 
arteries  obliquely  downwards.  Running  down 
from  the  umbilicus  in  the  middle  line  is  also  the 
remains  of  the  urachus.  In  the  fo3tus  the  spot 
where  the  three  vessels  part  company  is  about  the 
centre  of  the  navel,  and  it  thus  happens  that  in  a 
congenital  umbilical  hernia  the  gut  as  it  escapes 
separates  the  three  vessels,  which  become  to  some 
extent  spread  over  it.  The  congenital  hernia,  in- 
deed, works  its  way  in  among  the  structures  of 
the  cord  and  receives  its  main  coverings  from 
them.  These  hernise  are  fortunately  rare,  for  in 
certain  instances  they  extend  some  way  into  the 
cord,  and  in  at  least  two  reported  cases  the  gut 
was  cut  across  by  the  accoucheur  in  dividing  the 
cord  at  birth.*  As  the  abdomen  increases  in 

*  The  congenital  hernia  must  be  distinguished  from  the  infantile 
umbilical  hernia  so  commonly  met  with  after  separation  of  the  cord.  For 
an  account  of  these  congenital  hernise,  see  paper  by  the  Author  in  the 
Lancet,  1881,  i.  323. 


xvn]  PATENT  URAGHUS  355 

height  the  contraction  of  the  two  obliterated 
arteries  and  of  the  urachus  drags  upon  the  cica- 
trix  and  pulls  it  backwards  and  downwards. 

In  some  cases  there  is  found  at  the  navel  a 
fistula  from  which  urine  is  discharged.  This  is 
due  to  a  patent  urachus.  The  urinary  bladder 
is  formed  from  the  allantois;  and  the  part  of 
the  allantois  between  the  bladder  and  the  navel 
forms  the  urachus,  in  which  the  lumen  is  usually 
obliterated,  although  it  may  remain  patent.  In 
one  instance  of  patent  urachus  the  abnormal 
opening  was  1  inch  in  diameter.  The  patient,  a 
man  aged  40,  had  a  stone,  which  was  extracted 
by  passing  the  finger  into  the  bladder  through 
the  opening  at  the  umbilicus. 

Sometimes  a  fistula  discharging  faeces  is  met 
with  at  the  navel.  This  depends  upon  the  per- 
sistence of  the  vitello-intestinal  duct,  a  passage 
that  at  one  time  connects  the  intestine  of  the  early 
foetus  with  the  yolk-sac,  which,  as  development 
proceeds,  comes  to  be  situated  at  the  placental  end 
of  the  umbilical  cord.  In  99  per  cent,  of  foetuses 
this  communication  disappears,  but  in  1  per 
cent,  it  remains  as  a  duct,  cord,  or  diverticulum. 
When  the  intestinal  end  persists  it  is  known  as 
Meckel's  diverticulum,  and  springs  from  the  ileum 
some  2  or  more  feet  above  the  ileo-csecal  orifice. 
This  foetal  relationship  also  explains  the  presence 
of  a  fibrous  cord  which  is  sometimes  seen  con- 
necting Meckel's  diverticulum  with  the  umbilicus. 
The  fibrous  cord  may  cause  strangulation  of  the 
bowel  (Fig.  90,  p.  412). 

The  position  of  the  transverse  intersections  of 
the  rectiis  muscle  should  be  borne  in  mind. 
They  adhere  to  the  anterior  layer  of  the  rectus 
sheath,  but  not  to  the  posterior.  They  are  able 
therefore  to  some  extent  to  limit  suppurative 
collections  and  haemorrhages  beneath  the  sheath 
on  its  anterior  aspect.  This  muscle  is  often  the 
seat  of  one  form  of  "  phantom  tumour."  These 
tumours  are  mostly  met  with  in  the  hysterical 
and  hypochondriacal,  and  when  associated  with 


356  ABDOMEN  AND  PELVIS  [CHAP. 

some  vague  abdominal  symptoms  are  apt  to  mis- 
lead. They  are  due  to  a  partial  contraction  of 
the  muscle,  usually  to  a  part  between  two  inter- 
sections, and  are  said  to  be  more  common  in  the 
upper  part  of  the  rectus.  When  the  fibres  of  the 
muscle  are  contracted  the  "  tumour  "  is  obvious, 
but  when  they  relax  it  disappears.  The  phantom 
tumour,  however,  is  not  always  a  matter  of  little 
moment.  It  may  be  associated  with  grave  disease 
within  the  abdomen,  and  be  due  to  reflex  muscular 
contraction,  the  starting-point  of  such  reflex  act 
being  in  the  viscera.  These  localized  contractions 
may  provide  a  clue  to  the  seat  of  visceral  disease. 
Thus,  the  stomach  derives  its  chief  sensory  nerve 
supply  from  the  eighth  dorsal  segment  of  the 
cord ;  the  section  of  the  rectus  between  the  upper 
and  middle  inscriptions  is  also  supplied  from 
this  segment  through  the  eighth  dorsal  nerve; 
hence  contraction  of  this  section  may  be  asso- 
ciated with  disease  of  the  stomach.  The  rectus 
receives  nerves  from  the  lower  six  dorsal  nerves; 
the  section  at  the  umbilicus  is  supplied  by  the 
tenth.  I  (F.  T.)  have,  for  example,  seen  a  con- 
spicuous phantom  tumour  in  the  upper  part  of 
the  right  rectus  associated  with  cancer  of  the 
stomach,  with  ulcer  of  the  duodenum,  and  with 
malignant  disease  of  the  peritoneum. 

Other  vanishing  tumours  depend  upon  disten- 
sion of  the  intestines  by  flatus  or  by  fsecal 
matter.  In  great  distension  of  the  abdomen  the 
fibres  of  the  rectus  may  be  much  stretched,  since 
they  bear  the  brunt  of  the  distending  force. 
The  direction  of  the  fibres  also  renders  them 
liable  to  be  torn  in  opisthotonos,  or  extreme  arch- 
ing of  the  back,  or  tetanus.  Portions  of  the  muscle 
have  also  been  ruptured  by  muscular  violence,  as 
in  vaulting. 

The  lateral  muscles  of  the  front  abdominal 
wall  are  separated  from  one  another  by  layers 
of  loose  connective  tissue.  In  the  tissue  between 
the  internal  oblique  and  transversalis  are  found 
the  chief  nerves  and  arteries. 


xvn]  WOUNDS   OF  ABDOMEN  357 

Everywhere  the  peritoneum  is  bound  to  the 
abdominal  wall  by  subperitoneal  connective 

tissue.  In  the  pelvis  this  tissue  is  lax,  to  allow 
the  viscera  of  the  pelvis — the  bladder,  rectum, 
and  uterus — to  expand;  so,  too,  over  the  iliac 
fossae  and  on  the  anterior  abdominal  wall  for 
2  inches  above  the  inguinal  ligament  and  the 
symphysis  pubis;  but  above  this  level  and  on 
the  under  surface  of  the  diaphragm  it  binds  the 

Eeritoneum  down  closely.  The  looseness  of  this 
lyer  greatly  favours  the  spread  of  abscess,  to 
the  progress  of  which  it  offers  little  resistance. 
Such  an  abscess  may  spread  from  the  viscera, 
especially  from  those  that  have  an  imperfect 
peritoneal  covering,  as,  for  example,  the  kidney, 
the  vertical  parts  of  the  colon,  etc.  The  laxity 
of  this  tissue  has  been  of  service  in  certain 
surgical  procedures.  Thus  the  external  and 
common  iliac  arteries  can  be  reached  Jby  an  in- 
cision made  some  way  to  the  outer  side  of  the 
vessels  and  without  opening  the  peritoneum. 

Wounds  of  the  abdomen  may  give  trouble 
in  their  treatment,  since,  when  inflicted,  they 
may  open  up  several  layers  of  fascia  and  so  lead 
to  bagging  of  pus  and  to  the  spread  of  ^suppura- 
tion  should  an  abscess  follow  the  lesion.  The 
constant  respiratory  movements  of  the  belly-walls 
do  not  favour  that  rest  which  is  so  essential  to 
the  healing  of  wounds.  In  penetrating  wounds 
the  contraction  of  the  muscles  may  encourage 
the  protrusion  of  the  viscera,  especially  when  the 
incision  is  transverse  to  the  direction  of  the 
muscular  fibres.  In  reducing  small  portions  of 
protruded  viscera  it  is  quite  possible  to  push 
them  into  one  of  the  connective-tissue  spaces 
between  the  muscles,  or  into  the  subserous  tissue, 
instead  of  into  the  peritoneal  cavity.  In  applying 
sutures  to  wounds  involving  the  whole  thickness 
of  the  parietes  it  is  necessary  that  the  threads 
should  include  the  peritoneum,  so  that  early 
healing  of  that  membrane  may  be  brought  about. 
Without  such  precaution  a  gap  may  be  left 


358  ABDOMEN   AND  PELVIS  |ni\p. 

in  the  surface  of  the  peritoneum  which  would 
favour  the  formation  of  a  hernia  in  the  site  of 
the  old  wound. 

Blood-vessels.— The  only  arteries  of  any  mag- 
nitude in  the  abdominal  walls  are  the  inferior  or 
deep  epigastric  arteries,  some  branches  of  the  deep 
circumflex  iliac,  the  last  two  intercostal  vessels, 
the  superior  epigastric,  a  branch  of  the  internal 
mammary,  and  the  abdominal  divisions  of  the 
lumbar  arteries.  The  superficial  vessels  are  of 
small  size. 

The  superficial  veins  on  the  front  of  the 
abdomen  are  numerous,  and  are  very  distinct 
when  varicose.  A  lateral  vein,  extending  from 
the  axilla  to  the  groin,  uniting  the  axillary  and 
femoral  veins,  is  often  rendered  in  this  way  very 
prominent.  The  surface  abdominal  veins  may 
take  no  part  as  alternative  blood  channels  in 
cases  of  obstruction  of  the  inferior  vena  cava. 
Clinical  experience  shows  that  these  veins  may 
be  also  enormously  varicose  in  instances  where 
the  inferior  cava  is  quite  patent.  In  one  case 
under  my  (F.  T.'s)  care  there  was  extensive 
varicosity  of  the  surface  veins,  from  the  pectoral 
region  to  the  groin,  which  involved  one  side 
of  the  body  only.  It  has  been  shown,  more- 
over, that  the  valves  of  these  vessels  are  so 
arranged  that  the  blood  in  the  surface  veins 
above  the  navel  goes  to  the  axilla,  while  that 
in  the  veins  of  the  subumbilical  region  runs  to 
the  groin.  In  the  neighbourhood  of  the  umbilicus 
these  veins  are  connected  with  the  portal  vein 
in  the  liver  through  anastomotic  venous  channels 
in  the  falciform  ligament  of  the  liver  (Sappey). 
Hence,  in  cases  where  the  portal  circulation  is 
obstructed  by  disease  of  the  liver  or  partial 
obliteration  of  the  portal  vein,  some  of  the  portal 
blood  makes  its  way  to  the  superficial  epigastric 
veins  through  the  umbilical  communication.  In 
such  cases  the  blood  is  found  to  flow  away  from 
the  umbilicus. 

As    regards    the    surface     lyiiipliatirs   of    the 


xvii]        NERVES   OF  ABDOMINAL  WALL  359 

front  of  the  abdomen,  it  may  be  said  in  general 
terms  that  those  above  the  umbilicus  go  to  the 
axillary  glands,  and  those  below  to  the  glands 
of  the  groin. 

Nerves.  —  The  abdominal  wall  is  supplied  by 
the  lowest  six  dorsal  or  intercostal  nerves,  and 
by  the  first  lumbar  nerve  (Fig.  79).  They  run 


DlAP/HRAQMATIC 

CARDIAC 
OESOPHACEAL 


VESICAL 

REAIALTESTICULAR 


Fig.  79. — Showing  approximately  the  areas  of  skin  supplied 
by  spinal  nerves  on  the  anterior  surface  of  the  trunk. 

The  areas  are  marked  on  the  left  side  by  dotted  lines,  and  the  number 
of  the  spinal  nerve  by  which  each  is  supplied  is  stated.  The 
nerves  are  shown  on  the  right  side.  The  red  stippled  areas  show 
the  regions  to  which  pain  is  commonly  referred  in  connexion 
with  visceral  disease— according  to  the  observations  of  Sir  James 
Mackenzie.  The  pain  radiates  towards  the  unenclosed  part  of 
each  area. 

obliquely  to  the  long  axis  of  the  abdomen  down- 
wards and  inwards  from  the  sides  to  the  middle 
line,  and  hence  are  damaged  more  extensively  in 
vertical  than  in  oblique  incisions.  Their  direction 


360  ABDOMEN  AND  PELVIS  [CHAP. 

is  represented  by  a  continuation  of  the  lines 
of  the  ribs :  thejr  are  placed  parallel  to  one 
another  and  at  fairly  equal  distances  apart.  It 
is  important  to  note  that  they  supply  not  only 
the  abdominal  integument  and  the  peritoneal 
lining,  but  also  the  muscles,  viz.  the  rectus,  the 
two  oblique  muscles,  and  the  transversalis.  If 
a  cold  hand  be  suddenly  placed  upon  the  belly 
the  muscles  at  once  contract  and  the  abdomen  is 
instinctively  rendered  rigid.  The  skin,  muscles, 
and  peritoneum  in  every  section  of  the  wall  are 
linked  up  to  common  centres  in  the  spinal  cord 
by  means  of  afferent  or  sensory  fibres  and  efferent 
or  motor  fibres.  Hence,  when  the  skin  or  peri- 
toneum of  a  section  is  stimulated,  by  touch, 
heat,  cold,  or  injury,  a  stimulus  is  reflected  to 
the  underlying  muscles,  causing  them  to  contract. 
The  safety  of  the  viscera,  at  least  so  far  as 
protection  from  contusions  is  concerned,  depends 
upon  the  readiness  with  which  they  can  con- 
tract at  the  first  indication  of  danger.  As 
has  been  already  stated,  the  viscera  have  a  very 
efficient  protection  against  the  effects  of  blows 
when  the  muscles  of  the  belly  are  in  a  state  of 
rigid  contraction  (p.  352).  The  sensitive  skin  acts 
the  part  of  a  sentinel,  and  the  intimate  asso- 
ciation of  the  surface  nerves  with  the  muscular 
nerves  allows  the  warnings  of  this  sentinel  to  be 
readily  given  and  immediately  acted  upon.  The 
rigidity  of  the  muscles  in  certain  painful  affec- 
tions of  the  skin  over  the  abdomen  is  often  very 
conspicuous.  The  case  of  a  man  with  a  burn 
over  the  belly  might  be  instanced.  While  the 
burn  is  protected  by  the  dressings  the  abdominal 
muscles  are  lax  and  the  parietes  move  with  the 
respiratory  act.  The  moment  the  dressings  ^re 
removed,  the  surface  becoming  painful,  its  spinal 
centre  is  excited  and  the  muscles  at  once  contract 
and  the  belly  becomes  rigid. 

It  will  be  noticed  that  six  of  the  abdominal 
nerves  supply  intercostal  muscles,  and  are  thus 
intimately  associated  with  the  movements  of  re- 


xvii]        NERVES   OF  ABDOMINAL  WALL          361 

spiration.  The  abdominal  muscles  are  of  course 
concerned  in  the  same  movements.  These  associa- 
tions are  illustrated  when  cold  water  is  suddenly 
dashed  over  the  belly.  The  subject  of  the  experi- 
ment at  once  experiences  a  violent  respiratory 
movement  in  the  form  of  a  deep  gasp. 

There  are  other  practical  points  about  these 
nerves.  In  caries  of  the  spine,  and  in  certain 
injuries  to  the  column,  the  spinal  nerves  may 
suffer  injury  as  they  issue  from  the  vertebral 
canal.  This  injury  may  show  itself  by  modified 
sensation  in  the  parts  supplied  by  such  nerves. 
Thus  in  Pott's  disease  the  patient  often  com- 
plains of  a  sense  of  tightness  about  the  abdomen, 
as  if  a  cord  were  tied  around  it.  This  sense  of 
constriction  depends  upon  an  impaired  sensation 
in  the  parts  supplied  by  a  certain  pair  of  nerves ; 
or,  if  the  sense  of  constriction  be  wider  spread, 
by  two  or  more  pairs  of  nerves.  In  other  cases 
a  sense  of  pain  may  take  the  place  of  that  of 
constriction.  It  would  hardly  be  believed  that 
spinal  disease  has  been  mistaken  for  "  belly- 
ache." But  many  such  cases  have  been  recorded. 
A  child  complains  of  pain  over  the  pit  of  the 
stomach  or  about  the  umbilicus,  and  this  feature 
may  quite  absorb  for  a  while  the  surgeon's  atten- 
tion. The  abdomen  is  carefully  poulticed,  while 
the  only  mischief  is  in  the  vertebral  column. 
A  case  came  under  my  (F.  T.'s)  notice  in 
which  a  man  complained  of  intense  and  abiding 
pain  over  the  stomach.  The  pain  was  made 
worse  by  food,  and,  as  all  means  used  failed  to 
relieve  it,  the  abdomen  was  opened  by  an  ex- 
ploratory incision.  Nothing  abnormal  was  dis- 
covered. A  little  later  it  became  evident  that 
the  pain  was  due  to  a  malignant  tumour  situated 
in  the  bodies  of  the  dorsal  vertebrae.  There  had 
never,  before  the  operation,  been  any  suspicion 
of  spinal  disease.  The  site  of  the  painful  part 
depends,  of  course,  upon  the  position  of  the 
spinal  ailment,  and  so  the  cutaneous  symptoms 
may  serve  to  localize  the  caries  in  the  vertebras. 

M* 


362  ABDOMEN  AND  PELVIS  [CHAP. 

Thua  the  skin  over  the  "pit  of  the  stomach"  is 
supplied  by  the  sixth  and  seventh  dorsal  nerves, 
and  the  tenth  nerve  is  nearly  in  a  line  with  the 
umbilicus.  The  position  of  the  areas  supplied 
by  each  spinal  nerve  on  the  trunk  is  shown  in 
Fig.  79.  The  umbilicus  may  be  at  the  upper  or 
lower  border  of  the  area  of  the  tenth,  accord- 
ing to  the  individual.  A  spinal  root  may  be 
cut  and  yet  scarcely  a  trace  of  anaesthesia  may 
result  owing  to  the  overlapping  of  the  nerve 
distributions. 

Not  only  may  a  lesion  at  the  origin  of  a  spinal 
nerve  give  rise  to  a  pain  referred  by  the  patient 
to  the  abdomen,  but,  as  may  be  readily  understood 
from  the  fact  that  the  nerves  of  the  abdominal 
wall  also  supply  the  lower  half  of  the  thorax, 
thoracic  lesions  may  give  rise  to  symptoms  which 
are  referred  to  the  abdomen.  Pain  or  tender 
areas  in  the  upper  part  of  the  abdomen  may  be 
actually  due  to  a  pleurisy  in  the  lower  part  of 
the  thorax. 

Although  the  course  of  the  spinal  nerves  in 
the  body-wall  is  oblique — following  the  axes  of 
the  ribs — yet  in  their  final  distribution  they  sup- 
ply zones  of  skin  which  approximately  pass  hori- 
zontally round  the  body.  This  is  due  to  the  fact 
that  the  posterior  primary  divisions  and  lateral 
cutaneous  branches,  before  they  reach  their  areas 
of  skin,  descend  to  the  same  level  as  the  anterior 
cutaneous  nerves — the  terminal  branches  of  the 
anterior  divisions.  Indeed,  the  lateral  cutaneous 
nerves  of  the  lower  segments,  as  the  lower  limb 
is  approached,  actually  descend  farther  than  the 
anterior  cutaneous  nerves  (Fig.  79).  The  hori- 
zontal arrangement  of  the  skin  areas  is  demon- 
strated ^by  -the  distribution  of  the  cutaneous 
lesions  in  herpes  zoster — a  disease  which  is  now 
ascribed  to  a  lesion  of  the  ganglia  of  the  pos- 
terior roots. 

The  nerves  of  the  body-wall  have  still  more 
important  associations,  viz.  visceral  associations. 
The  cord-centres  with  which  the  body-wall  nerves 


xvn]         NERVES   OF  ABDOMINAL  WALL         363 

are  connected  are  also  in  communication  with 
the  viscera  of  the  abdomen  and  thorax  through 
the  sympathetic  system.  The  visceral  spinal 
centres  are  in  close  communication  with  corre- 
sponding somatic  spinal  centres.  Hence  diseased 
conditions  in  the  abdominal  viscera  give  rise  to 
disturbance  in  the  corresponding  cord^centres, 
and  the  brain,  being  accustomed  to  localize  pain 
only  along  the  somatic  nerves,  makes  a  mistake 
and  refers  the  pain  along  the  spinal  nerve  of 
the  segment  disturbed.  Not  only  is  pain  referred, 
but  the  skin  supplied  from  the  disturbed  spinal 
centres  becomes  tender ;  and  through  a  study  of 
these  areas  of  tenderness  Head  has  been  able  to 
localize  the  visceral  centres  in  the  spinal  cord, 
thus  affording  the  surgeon  a  means  for  increased 
accuracy  of  diagnosis.  The  abdominal  viscera 
are  supplied  from  the  sixth  dorsal  to  the  first 
lumbar  spinal  segments,  the  nerves  m  passing  to 
their  destinations  through  the  rami  communi- 
cantes,  splanchnic  nerves,  and  sympathetic 
plexuses  of  the  abdomen.  No  visceral  nerves 
escape  by  the  second,  third,  or  fourth  lumbar 
nerve  roots,  hence  these  are  never  the  seats  of 
visceral  referred  pains.  The  pelvic  viscera  are 
supplied  from  the  fifth  lumbar  to  the  third  or 
sometimes  fourth  sacral  nerve  through  the  nervi 
erigentes. 

It  is  important  to  remember,  too,  that  there 
are  three  systems  of  nerves  in  the  belly-wall : 
(1).  the  nerves  to  the  skin;  (2)  the  nerves  to  the 
muscles  (motor  and  sensory) ;  (3)  the  nerves  to  the 
parietal  peritoneum.  Any  one  or  all  of  these  three 
sets  may  be  the  seat  of  referred  pain,  the  most 
common  being  the  muscular  nerves.  The  pain 
elicited  by  pressure  on  the  muscles  or  by  move- 
ments is  ^usually,  but  erroneously,  regarded  as 
situated  in  the  diseased  viscus.  The  tonus  and 
condition  of  the  muscles  of  the  abdominal  parietes 
are  influenced  by  the  condition  of  the  viscera 
through  the  interconnexion  of  their  nerve-centres 
in  the  spinal  cord. 


364  ABDOMEN  AND  PELVIS  [CHAP. 

The  following  are  the  segments  with  which 
each  viscus  is  connected  (Head):  — 

Stomach,  (>,  7,  8,  9  D.  Prostate,    10,    11   D.,  5  L  , 

Intestine,  !),  10,  11,  12  D.  1,  2,  3  S. 

Rectum  2348  Epididymis,  11,  12  D.,  1  L. 

.turn,  2,  3,  4  S.  Tegtis  and  Q  1()  D 

Liver  and  gall-bladder,  7,  Appendages  of  uterus,  11, 

8,  9,  10  D.  12  D,  "i  L. 

Kidney  and  ureter,  10,  11,  Uterus,  10,  11,  12  D.,  1  L., 

12  D.,  1  L.  3,  4  S. 

This  nerve  relationship  is  illustrated  in  dis- 
ease in  many  ways.  Thus,  in  acute  peritonitis 
and  in  laceration  of  certain  of  the  viscera  the 
abdominal  muscles  become  rigidly  contracted,  so 
as  to  ensure  as  complete  rest  as  possible  to  the 
injured  parts.  In  acute  peritonitis,  again,  the 
belly  is  very  hard,  the  muscles  are  rigid,  and 
the  respirations  purely  thoracic;  and  so  hyper- 
sensitive are  the  spinal  centres,  because  of  the 
inrush  of  visceral  stimuli,  that  the  patient  is 
frequently  unable  to  tolerate  even  the  most  trifling 
pressure  on  the  skin  or  wall  of  the  abdomen. 

Congenital  deformities  of  the  abdomen.— 
At  the  end  of  the  second  month  of  develop- 
ment, part  of  the  intestine  projects  through  the 
widely  open  umbilicus  within  the  cord  when  it 
is  only  covered  by  the  transparent  membrane  of 
that  structure.  In  the  third  month  the  intestines 
retreat  within  the  abdomen,  the  cavity  within  ^  the 
cord  becoming  obliterated  and  the  umbilicus 
closed.  The  process  of  retraction  of  the  intestine 
may  fail,  or  even  an  opposite  process  may  occur — 
other  contents  being  added  to  those  normally 
found  within  the  cord.  Thus  result  the  various 
forms  of  congenital  exomphalos,  which  may  vary 
in  severity  from  a  small  hernia  to  a  protrusion 
of  the  whole  of  the  more  movable  viscera.  One  of 
the  most  remarkable  deformities  is  that  known  as 
extroversion  of  the  bladder  (ectopia  vesicae).  Here, 
not  only  is  a  part  of  the  belly-wall  apparently 
absent,  but  also  a  part  of  the  genito-urinary 


xvn]         EXTROVERSION   OF  BLADDER 


365 


apparatus.  In  complete  cases  there  is  a  defect 
in  the  abdominal  wall  from  the  umbilicus  to 
the  urethra.  There  is  a  widely  open  or  defective 
symphysis  pubis,  and  the  anterior  wall  of  the 
bladder,  the  principal  part  of  the  penis,  and 
the  whole  of  the  roof  of  the  urethra  are  absent 
(Fig.  80).  The  interior  of  the  bladder  and  urethra 
are  laid  open  and  form  part  of  the  anterior 


MEMBRANE  OF  BLADDER 


Fig.  80. — Condition  of  parts  in  extroversion  of  the  bladder. 

abdominal  wall.  The  unprotected  or  vesical  area 
offers  a  weak  resistance  to  the  descent  of  the 
viscera,  and  bulges  outwards  when  the  patient 
sits  or  stands  up.  The  scrotum,  also,  as  might 
be  expected  from  a  reference  to  the  development 
of  that  part,  is  bifid. 

HERNIA 

1.    Inguinal    hernia. — In   this  form   of   rup- 
ture  the   herniated   bowel    occupies   the   inguinal 


366  ABDOMEN  AND  PELVIS  [CHAP. 

canal  for  the  whole  or  part  of  its  entire  length. 
This  canal  runs  obliquely  from  the  internal, 
deep,  or  abdominal,  to  the  external,  superficial,  or 
inguinal  ring,  and  is  about  1|  inches  in  length. 
It  represents  the  track  followed  by  the  testis 
in  its  descent  to  the  groin.  It  is,  in  a  sense, 
a  passage  right  through  the  abdominal  wall, 
and  is  occupied  by  the  spermatic  cord.  It  is 
not  a  free  canal,  however,  in  the  same  sense  as 
one  would  speak  of  an  open  tube,  but  is  rather  a 
potential  one,  a  tract  of  tissue  so  arranged  as  to 
permit  of  a  body  being  thrust  along  it.  It  is  a 
breach  in  the  abdominal  wall,  not  a  doorway; 
a  breach  that  is  forcibly  opened  up  and  widened 
in  the  acquired  forms  of  hernia.  When  a  hernia 
occupies  the  inguinal  canal  it  is  covered  in 
front  by  the  integuments,  the  external  oblique 
aponeurosis,  and  the  lower  fibres  of  the  inter- 
nal oblique  and  transversalis  muscles.  It  rests 
behind  upon  the  transversalis  fascia,  the  con- 
joined tendon,  and  the  triangular  fascia  (reflected 
inguinal  ligament) ;  over  it  arch  the  transverse 
and  internal  oblique  muscles,  while  below  it  is 
the  angle  formed  by  the  union  of  the  inguinal 
(Poupart's)  ligament  with  the  transversalis  fascia. 
The  herniated  bowel  is  contained  within  a  "sac," 
which  is  always  formed  of  peritoneum.  In  con- 
genital hernia  the  sac  exists  already  formed 
as  an  abnormally  patent  "processus  vaginalis." 
In  acquired  hernia  the  sac  consists  of  that  part 
of  the  parietal  peritoneum  which  the  gut  pushes 
before  it  in  its  descent. 

The  external  or  superficial  ring,  |  an  inch 
external  to  and  above  the  pubic  spine,  is  readily 
felt  by  invaginating  the  scrotum  with  the  point 
of  the  finger  and  then  passing  the  digit  up  in 
front  of  the  cord  (Fig.  81).  If  the  nail  be  kept 
against  the  cord  the  pulp  of  the  finger  can  readily 
recognize  the  triangular  slit-like  opening.  Under 
ordinary  circumstances  in  adults  it  will  just  admit 
the  tip  of  the  little  finger.  The  internal  ring 
is  situated  about  \  an  inch  above  Poupart's 


XVIl] 


INGUINAL  HERNIA 


367 


ligament,  midway  between  the  symphysis  pubis 
and  anterior  superior  iliac  spine.  This  is  the 
femoral  point;  it  lies  directly  over  the  femoral 
artery  as  that  vessel  escapes  from  the  abdomen 
beneath  Poupart's  ligament  (Fig.  81). 

There  are  two  principal  forms  of  inguinal  hernia, 
which  can   be  best   understood   by   a  view   of  the 


/"  "111! 


VERT. 


Fig    81.— Surface   markings  for  the   inguinal   and   femoral 
canals. 

A  S.S.=  anterior  superior  spine  of  ilium.  Int.  abdom.  ring  =  deep 
or  abdominal  ring.  Ext.  abdom.  ring  =  superficial  or  inguinal  ring. 

anterior  abdominal  parietes  from  within  (Fig.  82). 
From  such  an  aspect  it  will  be  seen  that  the 
peritoneum  is  marked  by  three  linear  ridges  that 
run^  broadly  speaking,  from  the  umbilicus  to  the 
pelvic  brim.  One  of  these  ridges  follows  tho 
middle  line  from  the  navel  to  the  symphysis  and 
represents  the  urachus;  a  second,  which  may  be 
indicated  by  a  line  drawn  from  the  femoral  point 


368 


ABDOMEN  AND  PELVIS 


[CHAP. 


to  the  navel,  represents  the  inferior  or  deep  epi- 
gastric artery ;  while  between  these  two,  and  much 
nearer  to  the  epigastric  vessel  than  to  the  middle 
line,  is  the  line  formed  by  the  obliterated  hypo- 
gastric  artery  (Fig.  82).  By  means  of  these  ridges 
the  peritoneum  is  made  to  present  three  fossae — an 
external  to  the  outer  side  of  the  epigastric  artery, 
an  internal  between  the  urachus  and  the  hypo- 
gastric  artery,  and  a  middle  between  the  track 


URACHUS 
OBLIT.  HYPOQAST.  ART, 


DEEP  EPIQAST 
ART. 


EXT. 

EXT.   ILIAC  AKT. 
MID.  FOSSA 


FEMORAL  FOSSA 
NT.  FOSSA 


OBTURATOR    FOSSA 


Fig.  82. — The  sites  of  hernia  as  seen  on  the  inner  (peri- 
toneal) aspect  of  the  abdominal  wall.     (After  Merkel.} 

of  the  latter  vessel  and  the  epigastric  trunk. 
The  abdominal  ring  is  just  to  the  outer  side  of 
the  epigastric  artery,  its  site  being  indicated  by 
a  depression  in  the  peritoneum  (Fig.  82).  When 
a  hernia  follows  the  inguinal  canal  throughout 
its  entire  length,  it  is  called  oblique,  indirect, 
or  external;  "oblique"  or  "indirect"  from 
its  taking  the  oblique  direction  of  the  canal, 
"external"  from  the  position  of  its  neck  with 


xvnj  DIRECT  INGUINAL  HERNIA  369 

reference  to  the  epigastric  vessel.  The  coverings 
of  such  a  hernia  would  be  the  same  as  those  of 
the  cord,  viz.  the  skin,  the  superficial,  external 
spermatic  (intercolumnar),  cremasteric,  and  in- 
ternal spermatic  (infundibuliform)  layers  of 
fascia,  the  subperitoneal  tissue,  and  the  peri- 
toneum. When  the  hernia  escapes  to  the  medial 
side  of  the  inferior  epigastric  artery,  through  the 
space  known  as  the  recto-epigastric  (Hesselbach's) 
triangle,  it  is  called  a  direct  or  internal  hernia, 
for  reasons  that  will  be  obvious.  There  may  be 
two  forms  of  direct  hernia :  in  one  form  the 
gut  escapes  through  the  middle  fossa  above  de- 
scribed, in  the  other  through  the  inner  fossa 
between  the  hypogastric  artery  and  the  outer 
edge  of  the  rectus  muscle.  The  middle  fossa  is 
nearly  opposite  to  the  apical  or  outer  part  of  the 
inguinal  or  external  ring.  A  hernia^  escaping 
through  that  fossa  would  enter  the  inguinal  canal 
some  little  way  below  the  point  of  entrance  of  an 
oblique  hernia,  and  would  have  the  same  coverings 
as  that  hernia.  The  inner  fossa  corresponds,  or 
is  opposite  to,  the  inner  part  of  the  inguinal 
ring.  A  hernia  escaping  through  this  fossa  would 
bo  resisted  by  the  conjoined  tendon  and  the 
reflected  inguinal  ligament.  These  structures  are 
either  stretched  over  the  hernia  so  as  to  form 
one  of  its  coverings,  or  the  conjoined  tendon  is 
perforated  by  the  hernia,  or  thrust  aside.  In 
any  case  the  hernia  is  forced  almost  directly 
into  the  inguinal  ring. 

Direct  versus  indirect  inguinal  hernia. — The 
oblique  hernia  which  enters  the  abdominal  ring 
may  occupy  a  remnant  of  the  processus  vaginalis, 
and  be  therefore  developmental  in  origin,  but 
the  direct  is  never  congenital.  In  the  con- 
genital oblique  hernia  the  outline  of  the  in- 
guinal canal  and  the  relations  of  the  various 
parts  concerned  are  but  little  disturbed,  and  the 
differences  between  this  form  of  rupture  and  the 
direct  variety  are  conspicuous.  The  acquired 
oblique  hernia,  however,  does  not  present  such  a 


370  ABDOMEN  AND  PELVIS  [CHAP. 

contrast  to  the  direct  form  as  might  be  expected. 
In  the  first-named  rupture,  from  constant  drag- 
ging upon  the  parts,  the  abdominal  ring  becomes 
more  or  less  approximated  to  the  inguinal  ring, 
and  the  length  of  the  canal,  and  consequently  the 
obliquity  of  the  hernia,  is  considerably  reduced. 
Thus  the  axes  of  the  two  forms  of  rupture  do  not 
present  such  differences  as  to  make  their  nature  at 
once  obvious.  The  direct  hernia,  however,  on  re- 
duction, will  pass  directly  back  into  the  belly, 
while  the  indirect  will,  even  in  old  cases,  take  a 
slight  but  appreciable  direction  outwards.  After 
the  reduction  of  the  direct  hernia,  the  edge  of  the 
rectus  muscle  may  be  readily  felt  to  the  inner  side 
of  the  aperture.  The  direct  hernia  is  usually 
small  and  globular,  while  the  oblique  rupture  may 
attain  large  size,  and  tends  to  assume  a  pyriform 
outline. 

Forms  of  oblique  hernia  depending  upon  con- 
genital defects  in  the  "  vaginal  process."  The 
descent  of  the  testis. — It  is  well  known  that  the 
testis  in  the  foatus  descends  from  the  region  of 
the  kidney  into  the  scrotum  by  a  way  through  the 
abdominal  wall  that  is  afterwards  known  as  the 
inguinal  canal. 

Its  descent  is  preceded  by  the  passage  into 
the  scrotum  of  a  process  of  the  peritoneum,  the 
vaginal  process.  The  testicle  usually  enters  the 
abdominal  ring  about  the  seventh  month  of  foetal 
life,  and  by  the  eighth  month  is  in  the  scrotum. 
The  process  of  descent,  which  was  investigated 
and  made  clear  by  John  Hunter  some  150  years 
ago,  is  often  misunderstood.  The  gubernaculum 
(Fig.  83)^  is  a  solid,  bullet-like  plug  of  growing 
tissue  which,  by  a  pure  process  of  growth,  burrows 
its  way  through  the  abdominal  wall  into  the 
scrotum,  carrying  with  it  a  saccular  or  tubular 
process  of  peritoneum — the  processus  vaginalis — 
with  the  testicle  and  epididymis  enclosed  within 
the  process.  The  lower  or  growing  end  of  the 
gubernaculum  iscomlposed  of  rapidly  proliferating 
cells;  its  upper  part,  which  is  attached  to  the 


XVII] 


DESCENT   OF  THE   TESTIS 


371 


globus  minor  and  mesentery  of  the  testicle,  is 
composed  of  non-striated  muscular  tissue.  It 
can  be  understood  that  the  growing  end  of  the 
gubernaculum  may,  in  abnormal  circumstances, 
be  diverted  from  its  course  and  carry  the  testicle 
towards  the  root  of  the  penis,  or  outwards  in  the 
groin,  or  backwards  into  the  perineum,  thus  giving 
the  testicle  an  eccentric,  extrascrotal  position. 
It  was  Hunter's 


SPERM.  VESSELS  AND  VAS 
T.  ABDOM.  RINQ 


PROC.  VAGINALIS 


was 

opinion  —  and  the 
evidence  now  accu- 
mulated goes  to  sup- 
port him — that  the 
process  of  descent  is 
regulated  by  the  full 
development  of  the 
testicle,  probably  by 
an  internal  secretion. 
Hence,  if  the  testicle 
is  imperfect,  the 
process  of  descent  is 
arrested,  the  testicle 
being  left  in  the 
abdomen  or  stranded 
in  the  inguinal  canal. 
The  vaginal  pro- 
cess is  often  found 
open  at  birth ;  even 
in  children  three  or  r?.^ 
four  months  old,  the  *t*££2**!3 
communication  re- 
mains open  in  30  to 
40  per  cent,  of  cases. 
The  part  of  the 
processus  vaginalis  which  surrounds  the  testicle 
becomes  the  tunica  var/inalis,  while  the  elongated 
tubular  part  between  it  arid  the  abdominal  ring  is 
known  as  the  processus  funicularis.  The  manner 
in  which  the  processus  vaginalis  is  cut  off  is 
as  follows :  It  becomes  obliterated  in  two  places, 
at  the  deep  or  abdominal  ring  and  at  a  spot 
just  above  the  epididymis,  the  obliteration  usually 


PROC.  VAGINALIS 


GUBERNACULUM 


processus    vaginalis,  guber- 

naculum,    and    plica  vascu- 

laris  to   the  testicle  of  the 
human  foetus. 


372  ABDOMEN  AND  PELVIS  [CHAP. 

beginning  at  the  higher  point  first.  Supposing 
obliteration  to  have  taken  place  at  these  two 
points,  the  vaginal  process  between  them  will 
be  represented  by  an  isolated  tube.  This  soon 
shrinks,  closes,  and  dwindles  to  an  insignificant 
fibrous  cord.  It  may,  however^  remain  patent  in 
part,  and  if  fluid  accumulates  in  this  patent 
portion  an  "encysted  hydrocele  of  the  cord" 
is  produced.  As  regards  the  mode  of  closure, 
three  contingencies  may  happen,  each  giving  rise 
to  a  particular  form  of  hernia  :  (1)  the  "  process  " 
may  not  close  at  all;  (2)  it  may  close  at  the 
upper  point  only ;  and  (3)  it  may  close  at 
the  lower  point  only. 

1.  When  the  vaginal  process  is  entirely  open, 
gut    can   be    forced,    by    compression    of   the    ab- 
dominal musculature,  into  the  scrotum.     Such  a 
condition  is  called  a  congenital  hernia.     Here  the 
intestine  is   found  to  occupy  a  large  sac  of  the 
peritoneum,  the  open  orifice  of  which  is  placed  at 
the  abdominal   ring.     The  term   "congenital"   is 
misleading,   as  the  hernia  is  very  rarely  present 
at  birth,  although  it  is  common  in  early  life. 

2.  When  the  process  is  closed  only  at  the  ab- 
dominal  ring  the  unduly  large  tunica  vaginalis 
is  found  to  extend  up  to  that  orifice.     If  a  hernia 
forms  it  may  invaginate  the  processus  vaginalis. 
This  is  known  as  an  infantile  or  encysted  hernia. 
In  such  a  case  the  tunica  vaginalis  lies  in  front 
of   the   sac,    and   therefore   three   layers   of   peri- 
toneum   would    have    to    be    cut    through    before 
the  gut  could  be  reached.     The  term  "  infantile  " 
was  given  to  this  rupture  because  the  first  cases 
reported    were    met    with    in    infants;    the    term 
"  encysted,"    because    the    hernial    sac    was    con- 
sidered to  be  enclosed  by  the  sac  of  the  tunica 
vaginalis. 

3.  The  funicular  process  may  remain  open 
from  the  abdominal  ring  to  the  top  of  the  testicle, 
and  there  end,  the  normal  tunica  vaginalis  being 
beyond.  Hernia  into  this  process  is  called  a 
hernia  into  the  funicular  process. 


xvii]  FACTORS  IN  PRODUCTION  OF  HERNIA  373 

If,  in  the  dead  subject,  the  inguinal  canal 
be  opened  up,  and  an  attempt  made  to  draw 
a  piece  of  gut  down  from  the  abdomen  into  the 
scrotum,  it  will  be  found  that  this  cannot  be  done, 
owing  to  the  shortness  of  the  mesentery.  In  any 
case  of  scrotal  hernia,  therefore,  the  mesentery 
must  become  lengthened,  and  all  the  evidence  at 
our  disposal  points  to  this  elongation  as  having 
been  acquired  as  the  hernia  was  formed. 

Another  factor  which  must  be  considered  in 
the  production  of  hernia  is  the  tension  or  pressure 
within  the  abdomen.  When  a  labourer  lifts  a 
heavy  weight  from  the  ground,  the  musculature 
of  the  abdomen  is  thrown  into  vigorous  action, 
compressing  the  viscera  and  raising  the  pressure 
within  the  abdomen  to  100  mm.  of  mercury  or 
more.  When  a  child  cries,  coughs,  or  strains  at 
stool  there  is  a  sudden  rise  of  intra-abdominal 
pressure.  The  compressed  viscera  seek  out  the 
weakest  points  in  the  abdominal  wall,  which  are 
represented  by  the  abdominal  and  other  rings. 
The  escape  of  viscera  at  the  abdominal  ring  ^  is 
prevented  by  the  conjoined  parts  of  the  in- 
ternal oblique  and  transversalis.  Mr.  George 
Chiene  observed  that  when  a  patient  was  asked 
to  strain,  this  muscle  contracted  vigorously,  so 
that  a  finger  inserted  into  the  inguinal  canal 
was  gripped  between  the  conjoined  tendon  and 
Poupart's  ligament.  Hernise  are  notoriously 
frequent  in  men  who  have  to  lift  and  carry 
heavy  burdens. 

The  inguinal  canal  in  the  female  is  much 
smaller  and  narrower,  although  a  trifle  longer, 
than  it  is  in  the  male.  It  is  occupied  by  the  round 
ligament,  and  offers  such  resistance  that  acquired 
inguinal  hernia  is  as  rare  among  females  as  it  is 
common  among  men.  In  the  female  foetus  a  pro- 
cess of  peritoneum  descends  for  a  little  way  along 
the  round  ligament.  It  corresponds  to  the  pro- 
cessus  vaginalia  of  males,  and  is  known  as  the 
canal  of  Nuck.  If  this  process  remains  patent, 
as  it  not  infrequently  does,  it  may  lead  to  a 


374  ABDOMEN  AND  PELVIS 

rupture  that  corresponds  to  the  congenital  hernia 
of  males.  _  Indeed,  in  quite  early  life  the  inguinal 
rupture  is  about  the  only  form  met  with  in 
female  children,  if  exception  be  made  of  umbilical 
hernia.  Not  uncommonly  the  ovary  is  found  as 
one  of  the  contents  of  the  hern;al  sac — for  in  the 
newly-born  child  the  ovary  lies  above  the  level 
of  the  pelvic  brim  and  relatively  near  the  internal 
abdominal  ring.  In  all  such  instances  of  early 
inguinal  hernia  the  gut  has  travelled  down  a 
patent  processus  vaginalis. 

It  only  remains  to  be  said  that  in  endeavour- 
ing to  reduce  an  inguinal  hernia  by  taxis  the 
thigh  should  be  flexed  and  adducted,  for  in  this 
position  the  abdominal  parietes  that  bound  the 
inguinal  canal  are  the  most  relaxed.  This  posi- 
tion of  the  thigh  affects  the  inguinal  region 
mainly  through  the  attachments  of  the  fascia  lata 
to  the  inguinal  (Poupart's)  ligament. 

In  herniotomy  an  incision  is  made  along  the 
middle  of  the  tumour  and  in  its  long  axis,  being 
so  arranged  that  its  centre  shall  correspond  to 
the  inguinal  ring.  The  superficial  external  pudic 
artery  is  usually  divided  in  the  operation.  It  is 
impossible  to  distinguish  the  various  layers  of 
tissue  that  cover  the  hernia,  the  only  one,  as  a 
rule,  that  is  recognizable  being  the  layer  from 
the  cremaster.  In  dividing  the  constriction  it  is 
usually  recommended  to  cut  upwards  in  all^forms 
of  inguinal  hernia.  The  only  vessel  in  risk  of 
being  damaged  is  the  inferior  or  deep  epigastric. 
In  the  oblique  form  of  rupture  an  incision  directly 
upwards  would  quite  avoid  this  artery;  but  in  a 
direct  hernia,  where  there  is  reason  to  suppose 
that  the  vessel  is  in  close  connexion  with  the  neck 
of  the  sac,  it  is  well  that  the  incision  be  directed 
a  little  inwards  as  well  as  upwards.  ^  It  should 
be  remembered  that  the  incision  required  to  re- 
lieve a  constriction  is,  if  properly  applied,  of  the 
most  insignificant  character. 

Radical  cure  of  hernia. — In  all  operations  to 
mend  the  breach  in  the  abdominal  wall  caused  by 


xvn]  FEMORAL  HERNIA  375 

the  extrusion  of  a  hernia,  the  first  desideratum 
is  the  removal  of  the  peritoneal  sac.  Its  removal 
is  followed  by  a  cicatricial  contraction  of  the 
tissues  which  surround  its  ligatured  neck.  The 
second  aim  is  to  repair  the  sphincter  mechanism, 
represented  chiefly  by  the  conjoined  muscle  and 
its  tendon.  Its  origin  or  insertion  may  be 
shortened ;  its  nerve  supply  from  the  ilio-inguinal 
must  be  secured  and  protected;  the  gap  between 
the  inguinal  ligament  and  the  inguinal  border 
of  the  conjoined  muscle  may  be  diminished. 
Attempts  have  been  made  by  Bloodgood  to  trans- 
plant the  outer  fibres  of  the  rectus  abdominis 
from  the  outer  part  of  the  pubic  crest  to  the 
inner  part  of  the  inguinal  ligament,  but  it  is 
difficult  to  maintain  such  transplanted  parts  in 
health  and  thus  secure  the  canalicular  region. 

2.  Femoral  hernia.—  In  this  form  of  rupture 
the  gut  leaves  the  abdomen  through  the  femoral 
ring  (Fig.  84)  and  passes  down  into  the  thigh 
along  the  femoral  canal.  The  name  femoral  ring 
and  canal  is  given  to  the  narrow  interval  between 
the  femoral  vein  and  the  inner  wall  of  the  femoral 
sheath.  Like  the  inguinal  canal,  it  is  a  potential 
rather  than  an  actual  canal,  and  exists  only  when 
the  sheath  has  been  separated  from  the  vein  by 
dissection  or  by  a  hernial  protrusion  of  some  kind. 
The  femoral  canal  is  funnel-shaped,  about  ^  an 
inch  in  length,  and  ends  opposite  the  saphenous 
opening  (fossa  ovalis).  A  point  taken  on  the 
inguinal  ligament  midway  between  the  pubic 
spine  and  femoral  point  lies  directly  over  the 
femoral  ring;  the  centre  of  the  saphenous  open- 
ing is  situated  |  of  an  inch  below  this  point 
(Fig.  81).  Femoral  herniae  are  always  acquired, 
and  possess  a  sac,  made  by  themselves  out  of 
the  parietal  peritoneum  covering  the  femoral 
ring  and  its  vicinity.  The  ring  is  much  larger 
in  women  than  in  men,  and  thus  it  happens  that 
this  species  of  rupture  is  much  more  common  in 
the  former  sex.  As  the  gut  is  repeatedly  pressed 
— by  coughing,  lifting  heavy  weights,  straining — 


376 


ABDOMEN  AND  PELVIS 


[CHAP. 


against  an  unnaturally  capacious  ring,  it  pushes 
in  front  of  it  a  sac  of  peritoneum  and  the 
septum  crurale  (the  name  given  to  the  sub- 
peritoneal  tissue  that  covers  in  the  femoral  ring) 
and  enters  the  femoral  sheath.  The  adhesions  of 
the  sheath  limit  its  downward  progress  when  it 
has  travelled  about  £  an  inch,  and  it  therefore 
passes  forwards  through  the  saphenous  opening, 
pushing  before  it  the  cribriform  fascia  covering 
that  opening.  It  then  receives  a  covering  from 


INT.    EP/GASTfi/C   ARTERY 


HECT  ABOOM. 


FEMOR.ART. 
f EM  Off.  VEIN 


ABNORM.  OBTUR.  ART 

Fig.  84. — The   femoral  ring  and  its  relationships,   as  seen 
from  the  deep  or  peritoneal  aspect. 

the  superficial  fascia  and  the  skin.  Owing  to  the 
rigidity  of  the  structures  about  the  femoral  ring, 
the  neck  of  the  sac  must  always  be  small.  For 
similar  reasons  its  dimensions  while  in  the  femoral 
canal  must  of  necessity  be  insignificant,  but  when 
once  it  has  escaped  through  the  saphenous  open- 
ing the  loose  subcutaneous  fasciae  of  the  groin 
afford  it  ample  opportunity  for  increase.  When 
the  hernia  has  passed  through  the  saphenous  open- 
ing it  tends  to  mount  upwards  over  the  inguinal 
ligament,  in  the  direction  of  the  anterior  superior 


xvn]  FEMORAL  HERNIA  377 

iliac  spine.  Even  when  it  overlaps  the  ligament 
considerably  it  can  hardly  be  mistaken  for  an 
inguinal  hernia,  since  it  must  always  lie  to  the 
outer  side  of  the  pubic  spine.  The  hernial  sac 
is  superficial  to  the  deep  layers  of  the  inguinal 
fascia  (Scarpa's  fascia). 

Relations. — When  a  hernia  occupies  the  femoral 
canal  there  are  in  front  of  it  the  skin  and  super- 
ficial fasciae,  the  iliac  part  of  the  fascia  lata,  the 
fascia  cribrosa,  and  the  anterior  wall  of  the 
femoral  sheath.  Behind  are  the  posterior  wall 
of  the  femoral  sheath  and  pubic  portion  of  the 
fascia  lata,  the  pectineus  muscle,  and  the  bone. 
The  boundaries  of  the  femoral  ring  are,  in  front, 
the  inguinal  ligament  and  the  femoral  sheath; 
behind,  the  bone  covered  by  the  fascia  lata 
and  the  pectineus ;  on  the  inner  side,  the  con- 
joined tendon,  Gimbernat's  ligament  (ligamentum 
lacunare),  and  the  inner  part  of  the  deep  crural 
arch;  on  the  outer  side,  the  femoral  vein  in  its 
sheath  (Fig.  84).  The  spermatic  cord  lies  (in 
the  male)  just  above  the  femoral  ring,  and  the 
epigastric  artery  skirts  its  upper  and  outer  part 
(Fig.  84).  The  little  pubic  branch  of  this  artery 
passes  round  the  ring  to  ramify  over  Gimber- 
nat's  ligament.  In  two  cases  out  of  seven  the 
obturator  artery  arises  from  the  epigastric.  In 
10  per  cent,  of  cases  the  abnormal  obturator 
passes  on  the  inner  side  of  the  femoral  ring  and 
is  in  danger  of  being  wounded  in  operations  for 
strangulation  (Fig.  84) ;  in  other  cases  the  artery 
descends  to  the  outer  side  of  the  ring  or  may  cross 
it  (R.  Quain).  In  one  instance  where  the  vessel 
was  placed  internally  to  the  femoral  ring  the  puls- 
ations of  the  abnormal  artery  were  felt  before  the 
parts  were  divided.  In  addition  to  the  vessels 
about  the  ring  there  is  also  a  pubic  vein,  which, 
ascending  from  the  obturator  vein  in  the  thyroid 
foramen,  enters  the  external  iliac  vein. 

The  size  of  the  femoral  canal  and  the  degree 
of  tension  at  its  orifices  vary  greatly  with  the 
position  of  the  limb.  If  the  thigh  be  extended, 


378  ABDOMEN  AND  PELVIS  [CHAP. 

abducted,  and  rotated  outwards,  these  parts  are 
made  very  tense,  while  they  are  the  most  lax  when 
the  limb  is  flexed,  adducted,  and  rotated  inwards. 
It  is  consequently  in  the  latter  position  that 
the  thigh  should  be  placed  when  taxis  is  being 
attempted. 

In  herniotomy  the  incision  is  made  along  the 
inner  side  of  the  tumour,  and  is  so  arranged 
that  its  centre  corresponds  to  about  the  upper 
part  of  the  saphenous  opening.  The  constriction 
is^  usually  at  the  neck  of  the  sac,  and  caused  by 
Gimbernat's  ligament.  It  is  divided  by  an  in- 
cision directed  upwards  and  inwards.  In  repair- 
ing the  breach  caused  by  a  femoral  hernia  several 
of  the  surrounding  structures  are  utilized.  On 
the  surface  of  the  pubes,  just  above  the  ring 
is  the  ileo-pectineal  periosteal  ligament  (Cooper's 
ligament).  That  has  been  raised  and  sutured  to 
the  inguinal  ligament,  or  the  inner  part  of  the 
inguinal  ligament  may  be  sutured  to  the  pubes. 
.Fibres  of  the  pectineus  which  arise  from  the 
pubic  aspect  of  the  femoral  ring  (Fig.  84)  have 
been  brought  forwards  and  sutured  to  the  inguinal 
ligament,  or  the  outer  fibres  of  the  rectus  ab- 
dominis  may  be  transplanted  and  fixed  to  the 
ileo-pectineal  periosteal  ligament.  Mere  ligature 
of  the  neck  of  the  sac  leads  to  a  cicatricial 
adhesion  of  parts  within  the  ring,  often  sufficient 
to  prevent  recurrence  of  a  hernia. 

3.  Obturator  hernia.— In  this  form  the  gut, 
pushing  before  it  the  peritoneum,  the  subperi- 
toneal  fat,  and  the  pelvic  fascia,  escapes  through 
the  obturator  canal  (Fig.  82,  p.  368).  The  direction 
of  this  canal  is,  from  behind,  downwards,  forwards, 
and  inwards.  The  inguinal  is  separated  from  the 
femoral  canal  by  the  inner  part  of  Poupart's 
ligament;  the  femoral  is  separated  from  the  ob- 
turator by  the  horizontal  ramus  of  the  pubis. 

Beyond  the  canal  the  hernia  may  pass  between 
the  obturator  membrane  and  the  obturator  exter- 
nus  muscle  and  remain  deeply  placed,  or  it  may 
make  its  way  through  the  muscle  or  emerge  above 


XVIT]  RARE   FORMS   OF   HERNIA  379 

it  and  be  then  covered  by  the  pectineus  and  adduc- 
tor brevis.  The  obturator  artery  is,  as  a  rule, 
at  the  outer  and  posterior  part  of  the  sac;  it  is 
very  rarely  in  front  of  it.  The  obturator  nerve 
is  generally  found  to  the  outer  side  of  the  sac; 
less  commonly  it  is  in  front  of  it.  The  proximity 
of  the  nerve  renders  it  very  liable  to  be  pressed 
upon,  and  pain  along  the  nerve  is  often  a  marked 
feature  of  the  rupture.  The  hernia  presents 
beneath  the  pectineus  muscle,  to  the  inner  side  of 
the  capsule  of  the  hip,  behind  and  to  the  inner 
side  of  the  femoral  vessels,  and  to  the  outer  side 
of  the  adductor  longus  tendon.  Pain  on  moving 
the  hip  is  generally  a  conspicuous  symptom.  •  The 
obturator  externus  may  be  made  tense  by  rotation 
inwards  of  the  slightly  abducted  thigh.  This 
hernia  is  much  more  common  in  females;  and  it 
is  worthy  of  note  that  the  orifice  of  the  obturator 
canal  can  be  examined,  to  some  extent,  through 
the  vagina. 

4.  Bare  forms  of  hernia.  —  In  perineal 
hernia  the  sac,  covered  by  the  fascia  of  the 
abdominal  aspect  of  the  pelvic  diaphragm  (recto- 
vesical  fascia},  escapes  through  the  anterior  fibres 
of  the  levator  ani  muscle,  between  the  prostate 
and  the  rectum.  In  ischio-rectal  hernia  the  pro- 
trusion takes  place  into  the  ischio-rectal  fossa. 
In  pudenda!  hernia  the  sac  lies  in  the  posterior 
inferior  half  of  the  labium  pudendi,  escaping 
between  the  ascending  ramus  of  the  ischium  and 
the  vagina;  it  has  been  mistaken  for  a  cyst. 
In  sciatic  hernia  the  gut  escapes  through  the 
great  sacro-sciatic  notch  in  front  of  the  internal 
iliac  vessels,  above  or  below  the  pyriformis,  and 
presses  under  the  gluteus  maximus  muscle.  As 
regards  umbilical  hernia,  nothing  remains  to  be 
added  to  what  has  been  already  said  (p.  354), 
save  that  the  sac  from  its  position  nearly  always 
contains  omen  turn,  and  may  contain  stomach. 
In  lumbar  hernia  the  gut  escapes  in  front  of 
the  quadratus  lumborum  muscle,  and  appears 
on  the  surface  through  the  triangle  of  Petit 


380  ABDOMEN  AND  PELVIS  [CHAP, 

(the  gap  between  the  latissimus  dorsi  and  the 
external  oblique  muscles),  and  therefore  just 
above  the  highest  point  of  the  iliac  crest.  The 
sac  must  either  force  before  it  or  (in  cases  of 
injury)  come  through  the  fascia  lumborum  and 
internal  oblique  muscles,  since  these  structures 
form  the  floor  of  the  triangle.  A  hernia  may 
escape  through  the '"  upper  lumbar  triangle  "- 
a  gap  near  the  last  rib  where  the  aponeurosis  of 
the  transversalis  is  covered  only  by  the  latissimus 
dorsi.  Macready  (Lancet,  November  8,  1890)  col- 
lected twenty-five  examples  of  this  hernia.  Dia= 
phragmatic  hernia*  may  be  congenital  or  acquired. 
The  former  variety  is  by  far  the  more  common, 
and  is  due  to  simple  arrest  in  the  development 
of  the  diaphragm  and  persistence  of  the  original 
connexion  between  the  thorax  and  abdomen ;  the 
position  of  this  connexion  is  marked  by  the  fibrous 
interval  between  the  muscular  fibres  arising  from 
the  last  rib  and  those  springing  from  the  external 
arcuate  ligament  (lateral  lumbo-costal  arch).  The 
congenital  form  very  rarely  occurs  on  the  right 
side,  the  development  of  the  liver  securing  the 
closure  of.  the  pleuro-peritoneal  opening  on  that 
side.  In  the  acquired  form,  which  is  usually  the 
result  of  a  crushing  accident,  the  diaphragm  may 
be  lacerated  at  any  point,  but  in  the  majority  of 
instances  the  lesion  is  situated  in  the  left  dome 
over  the  stomach.  In  an  adult  subject  dissected  by 
Dr.  N.  Paterson  the  abdominal  contents  of  the  left 
hypochondrium  occupied  the  left  pleura!  cavity ; 
there  was  a  large  aperture  in  the  left  dome ;  the 
condition  had  not  been  recognized  during  life  and 
apparently  had  given  rise  to  no  marked  symptoms. 
Such  cases  of  unrecognized  diaphragmatic  hernia 
are  not  uncommon ;  but  symptoms  of  obstruction 
are  apt  to  occur  ultimately.  Of  the  organs,  the 
stomach  is  the  most  frequently  dislodged,  then 
the  transverse  colon,  omentum,  small  gut,  spleen, 
liver,  pancreas,  and  kidneys,  in  the  order  named. 

*  For  a  description  of  the  various  forms,  sre  Keith,  Brit.  Nfrf,  Jrnirn., 
Oct.  29,  1910. 


xvii]  DIVERTIGULA  381 

The  hernia  may  escape  through  the  foramen  for 
the  gullet,  but  never  through  that  for  the  vena 
cava,  nor  through  the  hiatus  aorticus.  A  partial 
hernia  of  the  stomach  through  the  cesophageal 
orifice  is  not  uncommon.  Mr.  W.  A.  E.  Waller 
has  recorded  the  case  of  a  young  man  aged 
19  who  died  with  obscure  symptoms  of  obstruc- 
tion. The  stomach  was  found  incarcerated  m  in 
the  oesophageal  orifice,  the  greater  part  having 
passed  into  the  left  pleural  cavity.  The  parts 
commonly  selected  are  the  connective-tissue  in 
tervals  between  the  sternal  and  costal  origins 
of  the  diaphragm  in  front  and  its  vertebral 
and  costal  origins  behind.  These  hernise  are  more 
common  in  males. 

Femoral  and  inguinal  diverticula. — Re- 
cently Mr.  R.  W.  Murray  has  called  attention  to 
the  frequency  with  which  diverticula  of  peri- 
toneum are  found  over  the  openings  of  the  femoral 
and  inguinal  canals  (see  Fig.  82,  p.  368).  In  200 
post-mortem  examinations  he  found  52  femoral 
and  13  inguinal  diverticula  and  yet  no  hernia. 
In  some  cases  the  inguinal  sacs  may  be  formed 
from  the  processus  vaginalis,  but  all  the  femoral 
forms  and  probably  the  majority  of  the  "inguinal 
are  caused  by  yielding  of  the  fibrous  tissue  of  the 
parietes  over  the  femoral  and  internal  abdominal 
rings.  In  these  regions  the  peritoneum  is  elastic 
and  so  loosely  bound  to  the  abdominal  wall  that 
it  may  be  evaginated  by  even  a  low  degree  of 
intra-abdominal  pressure.  In  all  forms  of  treat- 
ment, measures  should  be  taken  to  secure  a  firm 
adhesion  of  the  peritoneum  in  the  region  of  the 
abdominal  and  femoral  rings. 

POSTERIOR  ABDOMINAL  PARIETES 
The   lateral   and   posterior   walls  of   the  abdo- 
men   are    lined    inside    with    two     fasciae,     the 
transversalis  and  iliac.     The    transversalis  fascia 

lines  the  whole  of  the  transversalis  muscle,  and 
is .  much  thicker  below  than  above.  Above,  it 
joins  the  fascia  covering  the  diaphragm,  while 


382  ABDOMEN  AND  PELVIS  [CHAP. 

below  it  is  attached  to  the  iliac  crest  and  to 
the  whole  of  the  inguinal  ligament,  save  at  that 
spot  where  it  passes  into  the  thigh  to  form  the 
anterior  layer  of  the  femoral  sheath.  The  iliac 
fascia  encloses  the  ilio-psoas  muscle,  the  part 
over  the  psoas  being  the  thinner.  This  part  is 
attached  on  the  inner  side  to  the  sacrum,  and  to 
the  spine  at  the  points  corresponding  to  the  psoas 
origin.  Above,  it  is  attached  to  the  ligamentum 
arcuatum  internum  (lateral  lumbo-costal  arch), 
and  on  the  outer  side  to  the  anterior  layer  of 
the  lumbar  fascia  along  the  outer  edge  of  the 
psoas.  Below,  the  fascia  encloses  the  iliacus, 
and  is  attached  to  the  iliac  crest,  to  the  pelvic 
brim,  and  to  the  inguinal  ligament,  save  at 
that  part  where  the  membrane  passes  beneath 
the  ligament  to  form  the  posterior  wall  of  the 
femoral  sheath.  It  follows  the  ilio-psoas  muscle 
to  its  insertion,  and  ends  by  blending  with  the 
fascia  lata. 

The  arrangement  of  these  fasciae  greatly  influ- 
ences the  progress  and  direction  of  abscess.  Thus 
an  abscess  placed  beneath  the  transyersalis  fascia 
will  point  either  just  above  the  iliac  crest  or 
the  inguinal  ligament,  or  run  down  along  the 
spermatic  cord  and  distend  the  inguinal  canal. 

The  iliac  fascia  encloses  the  ilio-psoas  in  a 
very  distinct  osseo-aponeurotic  space.  Between  the 
fascia  and  the  muscle  (especially  its  iliac  division) 
there  is  a  good  deal  of  loose  connective  tissue, 
and  thus  every  facility  is  offered  for  the  progress 
of  subfascial  abscesses  in  this  region.  The  osseo- 
ajDoneurotic  space  is  practically  closed  on  all  sides 
within  the  abdomen,  and  is  only  open  below  where 
the  fascia  passes  with  its  muscle  into  the  thigh. 
This  opening  being  at  the  most  dependent  part  of 
the  space,  it  follows  that  the  psoas  or  iliac  abscess 
very  commonly  points  on  the  upper  part  of  the 
thigh,  just  to  the  outer  side  of  the  femoral  vessels. 
An  abscess  in  the  iliac  fossa,  although  most  likely 
to  reach  the  thigh,  might  mount  up  to  the  superior 
attachments  of  the  fascia,  and  point  at  the  iliac 


xvn]  ILIAC  ABSCESS  383 

crest  or  at  the  outer  part  of  Poupart's  ligament. 
Or  it  might  disregard  the  inner  attachments  of 
the  fascia  and  gravitate  into  the  pelvis.  If  the 
patient  should  occupy  for  long  the  recumbent  pos- 
ture, there  is  no  reason  why  it  should  not  extend 
upwards  along  the  psoas  muscle. 

The  term  iliac  abscess,  however,  is  often  ap- 
plied to  collections  that  are  not  within  the  space 
formed  by  the  iliac  fascia,  but  that  are  situated 
rather  in  the  subperitoneal  connective  tissue. 
This  tissue  is  very  extensive  and  lax  in  the 
iliac  fossa  in  order  to  allow  the  expansion  of 
the  peritoneum  which  necessarily  attends  the  fill- 
ing and  emptying  of  the  caecum,  C9lon,  bladder, 
uterus,  and  rectum.  Large  collections  of  puru- 
lent matter  may  form  in  it  or  may  spread  into  it 
from  the  pelvis.  Some  distance  above  Poupart's 
ligament  (1^  to  2  inches)  the  subserous  tissue 
becomes  dense  and  the  peritoneum  closely  bound 
down.  Hence  such  abscesses  remain  in  the  iliac 
fossa,  bulging  put  the  abdominal  wall  just  above 
the  inguinal  ligament,  and  occupying  the  angle 
formed  by  the  union  of  the  iliac  and  transversalis 
fasciae.  In  some  cases  they  are  disposed  to  extend 
into  the  pelvis. 

The  abscess,  when  in  the  subserous  tissue,  is 
brought  into  close  contact  with  certain  of  the  vis- 
cera, especially  with  the  caecum  and  the  iliac 
colon,  and  into  these  portions  of  the  colon  it  may 
open.  Thus,  I  (F.  T.)  have  seen  a  case  of  iliac 
abscess  due  to  pelvic  necrosis  which  opened  into 
the  iliac  colon,  and  at  the  same  time  discharged 
through  sinuses  about  the  groin.  In  this  case 
some  pus  passed  by  the  anus,  while  on  the  other 
hand  some  faecal  matter  escaped  by  the  groin. 
Retroperitoneal  abscesses  in  the  pelvis  (pelvic 
cellulitis)  may  mount  up  into  the  iliac  fossae,  may 
appear  as  "  iliac  abscesses,"  and  may  ultimately 
discharge  themselves  by  many  openings  in  the 
lower  parts  of  the  anterior  abdominal  wall. 

It  may  be  well  to  note  that  the  common  and 
external  iliac  vessels,  the  lymphatics,  and  the 


384  ABDOMEN  AND  PELVIS  [CHAP. 

ureters  are  outside  the  iliac  fascia,  and  rest  upon 
its  abdominal  surface,  while  the  anterior  crural 
nerves  and  abdominal  parts  of  the  lumbar  nerves 
are  within  the  osseo-aponeurotic  space.  Thus  the 
intrafascial  abscess  may,  with  little  difficulty, 
reach  the  thigh  by  following  the  iliac  vessels; 
while  the  extrafascial  collection  would  pursue  the 
anterior  crural  nerve. 

A  psoas  abscess,   or  abscess  within  the  fascial 
sheath  of  the  psoas  muscle,  is  usually  due  to  spinal 
caries,  although  it  may  appear  independently  of 
that  disease.     If  the  lumbar  spine  be  involved  the 
matter  can  pass  directly  into  the  substance  of  the 
muscle,  which  it  will  more  or  less  entirely  destroy. 
If  the  mischief  be  in  the  dorsal  spine,  the  matter 
gravitates   along   the   front   of   the   column   until 
it  reaches  the  diaphragm,  which  it  pierces  by  an 
inflammatory  process.     It  is  now  brought  into  re- 
lation with  the  heads  of  the  psoas,  and  has  to  pass 
through  a  narrow  strait.     The  pus,  following  the 
muscle,    at   last   reaches   the   thigh,    and    usually 
points,  just  below  the  groin,  to  the  outer  side  of 
the  femoral  vessels.     The  substance  of  the  psoas 
may  be  completely  replaced  by  an  abscess  cavity. 
Lumbar  region. — The  muscles  which  form  the 
lateral  and  posterior  walls  of  the  abdomen,  and 
fill   in   the  interval   between   the   iliac   crest   and 
the  lowest  rib,  are  the  external  oblique  and  latis- 
simus   dorsi,    the   internal    oblique,    the   transver- 
salis  muscle  with  its  fascia  lumborum,  the  erector 
spinse,    and   quadratus    lumborum.     The    distance 
from  the  iliac  crest  to  the  tip  of  the  nearest  rib 
(usually  the  eleventh)  varies  from  3  to  7  cm.,  the 
average  being  4'8  cm.,  a  little  less  than  2  inches 
(Addison). 

The  external  oblique  and  latissimus  dorsi  mus- 
cles are  separated  by  a  small  triangular  interval 
below  (the  triangle  of  Petit),  but  above  they  over- 
lap. The  interval  is  most  pronounced  in  women.  The 
outer  border  of  the  erector  spinse  (sacro-spinalis) 
affords  a  useful  landmark  in  the  lumbar  region. 
At  the  crest  of  the  ilium  the  outer  border  of 


xvn]  LUMBAR  ABSCESS  385 

the  quadratus  lumborum  extends  an  inch  beyond 
the  erector  spinse,  but  at  the  twelfth  rib  it  lies 
an  inch  internally  to  that  muscle  (Fig.  100,  p.  447). 
The  triangle  of  Petit  is  1|  to  2  inches  beyond 
the  erector  spinse,  or  just  behind  the  mid-point 
of  the  iliac  crest. 

Between  the  last  rib  and  the  iliac  crest  is 
stretched  the  dense  fascia  lumborum,  the  posterior 
aponeurosis  of  the  transversalis  muscle.  It  is 
pierced  near  the  rib  by  the  last  intercostal  artery 
and  nerve,  and  near  the  ilium  by  the  ilio-hypo- 
gastric  nerve  and  its  accompanying  artery.  It 
is  along  these  structures  that  an  abscess  may 
possibly  find  its  way  through  the  fascia  in  certain 
cases.  The  fascia  divides  behind  into  three  layers, 
to  enclose  in  definite  spaces  the  quadratus  and 
erector  spinse  muscles,  the  middle  layer  passing 
between  these  two  muscles  to  the  tips  of  the  trans- 
verse processes.  Within  these  spaces  or  compart- 
ments suppuration  may  be  for  some  time  limited. 
A  Lumbar  abscess  commencing  in  some  adjacent 
part,  as  in  the  spine  or  in  the  loose  tissue  around 
the  kidneys,  usually  spreads  backwards  by  piercing 
the  fascia  lumborum  or  the  quadratus  muscle. 

Treves's  operation  for  caries  of  the 
lumbar  vertebrae.  —  The  lumbar  vertebrae,  and, 
possibly,  the  last  dorsal,  may  be  reached  by  an 
incision  through  the  loin.  A  vertical  cut  is  made 
along  the  outer  edge  of  the  erector  spinse  muscle. 
The  fibres  of  that  muscle  having  ^been  drawn 
aside,  the  middle  layer  of  the  fascia  lumborum 
is  incised,  and  the  quadratus  lumborum  is  ex- 
posed. This  muscle  is  divided  vertically,  and  then 
the  front  of  the  vertebrse  may  be  reached  by 
introducing  the  finger  under  the  psoas  muscle. 
Through  such  an  incision  a  sequestrum  repre- 
senting the  whole  of  the  body  of  the  first  lumbar 
vertebra  has  been  removed.  The  lumbar  arteries 
are  avoided  by  keeping  close  to  the  transverse 
processes  of  the  vertebrse.  Through  this  incision  a 
psoas  abscess  may  be  most  conveniently  opened.  » 


CHAPTER  XVIII 

THE    PERITONEUM    AND    ALIMENTARY 
TRACT 

The  peritoneum. — Certain  of  the  viscera,  as 
for  example  the  stomach,  spleen,  and  small  in- 
testine, are  so  closely  invested  with  peritoneum 
that  they  could  not  be  wounded  without  that 
membrane  being  wounded  also.  Inflammatory 
affections  of  such  viscera  are  also  very  apt  to 
involve  the  peritoneum.  Other  organs,  such  as  the 
kidney,  descending  colon,  pancreas,  etc.,  are  so  im- 
perfectly covered  with  the  serous  membrane  that 
a  wound  of  those  organs  need  not  involve  it,  nor 
need  it  be  implicated  in  even  extensive  inflamma- 
tory changes.  Large  abscesses  may,  for  instance, 
form  about  the  kidney  and  discharge  themselves 
through  the  skin  without  any  peritonitis  being 
induced.  Spontaneous  perforation  of  the  small 
intestine  must  involve  the  peritoneum,  while,  on 
the  other  hand,  the  duodenum  and  ascending 
colon  may  become  perforated,  and  the  matter 
escape  into  the  subserous  tissue  without  the  serous 
membrane  being  in  any  way  involved.  It  is  note- 
worthy in  connexion  with  bacterial  infection  that 
it  is  singularly  easy  to  set  up  inflammation  of 
the  peritoneum  if  the  membrane  be  approached 
from  its  inner  surface,  but  comparatively  difficult 
if  it  be  approached  from  without.  Thus  a  small 
puncture  of  the  membrane  may,  on  the  one  hand, 
lead  to  fatal  peritonitis,  while,  on  the  other,  it 
may  be  extensively  torn  from  its  attachments 
(as  in  ligaturing  the  common'  iliac  artery  from] 
the  side)  without  any  peritonitis  following.  Or, 
386 


THE   PERITONEUM  387 

again,  a  little  pus  escaping  on  the  inner  surface; 
of  the  membrane  may  lead  to  inflammation,  while 
the  outer  surface  may  be  bathed  with  pus  for  a 
long  while  (as  in  large  perirenal  abscesses)  with- 
out any  peritonitis  being  produced.  To  under- 
stand these  effects  one  must  remember  that  septic 
matter,  on  the  free  surface  of  the  peritoneum, 
has  open  to  it  an  enormous  area  over  which 
it  may  spread  unrestrainedly  and  from  which  it 
may  be  readily  absorbed.  Indeed,  we  know  that 
fluid  substances  pass  quickly  from  the  peritoneal 
cavity  into  the  lymphatic  system.  Carmine  par- 
ticles suspended  in  fluid  are  found  within  the 
thoracic  duct  seven  minutes  from  their  injection 
within  the  cavity;  absorption  takes  place  most 
rapidly  in  the  subdiaphragmatic  area  (Dunbar 
and  Remy).  Inflammation  of  the  peritoneum 
may  lead  to  the  formation  of  a  great  variety  of 
bands  and  adhesions,  beneath  which  pieces  of 
intestine  may  be  caught  and  strangulated. 

The  peritoneum  will  allow  of  very  consider- 
able stretching  if  only  that  stretching  be  effected 
gradually.  This  is  frequently  seen  in  cases  of 
gradual  distension  of  the  bowel,  in  the  formation 
of  the  sac  in  hernia,  and  in  the  growth  of  retro- 
peritoneal  tumours.  Abrupt  stretching  ^  of  the 
membrane  leads  to  certain  rupture  of  it.  The 
parietal  peritoneum  may  be  ruptured  by  violence 
without  damage  to  any  of  the  viscera. 

The  great  omentum  is,  from  its  position,  very 
apt  £6  be  wounded.  In  small  wounds  of  the 
front  of  the  belly  it  very  often  protrudes  and  acts 
as  an  excellent  ^  plug  to  prevent  the  escape  of 
other  and  more  important  structures.  It  is  often 
found  in  hernia,  especially  in  umbilical  hernia, 
where  it  is  almost  constant.  Its  limits  vary,  and 
it  has  an  inclination  to  the  left  side.  This 
depends  unon  the  fact  that  the  omentum  is 
developed  from  the  mesogaster,  and  accounts  for 
the  fact  that  hernise  containing  omentum  are 
much  more  common  on  the  left  side.  The  omen- 
tum, like  the  other  parts  of  the  peritoneum,  is 


388  ABDOMEN  AND  PELVIS  [CHAP. 

apt  to  inflame,  and  to  contract  adhesions  to  the 
neighbouring  parts.  These  adhesions  are  often 
of  the  greatest  service  in  limiting  inflammatory 
and  hsemorrhagic  extravasations,  by  matting  the 
bowels  together  and  forming  spaces  between  them. 
In  perforation  of  the  bowel  or  appendix  from 
disease,  an  opportune  adhesion  of  the  omentum 
over  the  aperture  may  prevent  escape  of  the 
intestinal  contents. 

Large  masses  of  tissue  may  be  nourished 
through  an  adherent  omentum.  Thus,  when  the 
proper  blood  supply  of  an  ovarian  tumour  has 
been  cut  off  by  twisting  of  its  pedicle,  the  growth 
may  be  nourished  through  the  omentum,  if  that 
structure  is  adherent  to  it.  Rutherford  Morri- 
S9n  proposes  to  relieve  congestion  of  the  portal 
circulation  by  setting  up  an  anastomosis  between 
the  omental  vessels  and  the  systemic  circulation. 
When  an  adhesion  between  the  omentum  and 
parietal  peritoneum  is  produced  artificially,  large 
anastomotic  vessels  open  up  and  communicate 
with  the  vascular  network  beneath  the  parietal 
peritoneum,  thus  possibly  relieving  tension  in 
cases  of  obstructed  portal  circulation.  In  cases 
of  obesity  fat  collects  conspicuously  in  the  great 
omentum.  In  hernise  the  omentum  generally  con- 
tracts adhesions  to  the  sac,  and  becomes  irreduc- 
ible, or  it  may  form  a  kind  of  second  sac  about  the 
gut  itself  ("  omental  sac  ").  The  end  of  the  omen- 
tum, by  becoming  adherent  to  distant  parts,  as  to 
the  pelvic  viscera,  may  form  itself  into  a  firmly 
attached  band,  beneath  which  the  bowel  may  be 
fatally  strangled.  In  like  manner  the  intestine 
has  been  strangulated  through  slits  and  holes  that 
have  developed  in  the  omentum,  usually  as  a  re- 
sult of  inflammatory  adhesions.  The  functional 
meaning  of  the  great  omentum  is  by  no  means 
definitely  established,  but  it  undoubtedly  increases 
the  absorptive  area  of  the  peritoneum,  and  evi- 
dence is  not  lacking  to  show  that  it  takes  an  active 
part  in  repelling  bacterial  invasions  of  the  peri- 
toneal cavity.  Thus.  Dr.  B.  H.  Buxton  found 


xviii]  THE   MESENTERY      .  389 

that  the  mononuclear  white  corpuscles  of  the 
omentum  of  rabbits  were  soon  laden  with  typhoid 
bacilli  in  cases  where  artificial  cultures  had  been 
introduced  within  the  peritoneal  cavity. 

The  mesentery. — The  parietal  attachment  of 
the  mesentery  is  liable  to  some  variation.  The 
point  at  which  this  attachment  commences  above 
is  practically  constant.  It  corresponds  with  the 
ending  of  the  duodenum,  is  about  on  a  level  with 
the  lower  border  of  the  pancreas,  and  is  just  to 
the  left  of  the  second  lumbar  vertebra.  (See  p.  394.) 
From  this  point  the  insertion  of  the  mesentery 
follows  an  oblique  line  that  runs  downwards 
and  to  the  right,  crossing  the  great  vessels,  and 
then  ending  in  a  somewhat  uncertain  manner  on 
the  right  iliac  fossa  (Fig.  85,  p.  392).  The  parietal' 
attachment  of  the  mesentery  measures,  as  a  rule, 
about  6  inches.  From  its  oblique  attachment  it 
follows  that,  when  haemorrhage  takes  place  in  the 
abdomen  on  the  right  side  of  the  mesentery,  the 
blood  first  is  conducted  into  the  right  iliac  fossa; 
when  on  the  left  side,  into  the  pelvis.  This  may 
explain  the  circumstance  that  collections  of  blood 
are  more  common  in  the  right  than  in  the  left 
iliac  fossa. 

The  length  ^  of  the  mesentery  from  the  spine  to 
the  bowel  varies  in  different  parts  of  the  canal ; 
its  average  length  is  8  inches.  The  longest  part 
is  that  which  goes  to  the-  coils  of  intestine  lying 
between  a  point  6  feet  from  the  duodenum 
and  a  point  11  feet  from  the  same  part  of  the 
gut  (Troves).*  Such  coils  will,  therefore,  include 
5  feet  of  the  intestine,  and  the  mesentery  here 
may  reach  the  length  of  10  inches.  These  coils 
are  habitual  occupants  of  the  pelvis,  and  may 
be  easily  herniated.  If  the  fresh  body  of  an 
adult  be  opened,  and  the  condition  9f  the  viscera 
and  peritoneum  be  normal,  it  will  be  found 
that  it  is  impossible  to  drag  a  loop  of  small 
intestine  through  the  femoral  canal  (artificially 

*  See  "  The  Anatomy  of  the  Intestinal  Canal  and  Peritoneum  in  Man." 
London,  1885. 


390  ABDOMEN  AND  PELVIS  [CHAP. 

enlarged)  on  to  the  thigh,  or  down  the  inguinal 
canal  into  the  scrotum.  In  fact,  no  coil  can,  in 
any  part,  be  drawn  out  of  the  abdomen  below  a 
horizontal  line  on  a  level  with  the  spine  of  the 
pubes.  It  is  evident,  therefore,  that  in  femoral 
or  scrotal  hernia  the  mesentery  must  be  elongated 
or  its  attachments  lowered. 

Certain  holes  are  sometimes  found  in  the 
mesentery,  through  which  intestine  has  been 
strangulated.  Some  of  these  holes,  especially  those 
that  are  slit-like,  are  due  to  injury,  others  are 
due  to  absorption  from  pressure  or  congenital 
defect  of  the  mesentery. 

Cases  of  imperfect  attachments  of  the  mesen- 
tery have  been  frequently  recorded  of  late  years. 
The  primary  attachment  is  at  the  origin  of  the 
superior  mesenteric  artery,  from  which  point  a 
process  of  peritoneal  adhesion  or  fixation  extends 
during  the  foetal  life  towards  the  right  iliac 
fossa.  If  this  process  is  completely  arrested  then, 
the  whole  intestine  may  become  rotated  round 
the  superior  mesenteric  artery,  causing  obstruc- 
tion of  the  bowel,  or,  if  only  the  lower  part 
of  the  mesentery  remains  unattached,  the  loop 
formed  by  the  lower  part  of  the  ileum  and  com- 
mencement of  the  great  bowel  may  undergo  a 
rotation  and  cause  obstruction.  It  is  important 
to  remember  that  there  are  two  kinds  of  peri- 
toneal adhesions  or  bands,  those  formed  during 
foetal  life  when  the  mesentery  and  bowel  are 
being  fixed  to  the  posterior  wall  of  the  abdomen 
(developmental  adhesions),  and  those  formed  in 
later  life  as  the  result  of  disease  (pathological 
adhesions). 

Peritoneal  spaces  and  communications. — 
Owing  to  the  arrangement  of  the  peritoneum  the 
cavity  of  the  abdomen  is  divided  into  a  number 
of  potential  spaces  which  are  connected  together 
by  certain  definite  communications  or  routes. 
Alimentary  contents,  pus,  or  blood  escaping 
within  the  peritoneal  cavity  tend  to  collect  in 
certain  of  these  spaces  and  overflow  into  neigh- 


xvin]  PERITONEAL  SPACES  391 

bouring  spaces  in  well-defined  directions.^  Some 
writers  see  in  this  arrangement  of  the  peritoneum 
a  resemblance  to  the  watersheds  of  a  country,  and 
hence  the  potential  spaces  and  routes  are  some- 
times spoken  of  as  the  "  watersheds  of  the  peri- 
toneum." The  chief  of  these  spaces  are  :  (1)  The 
lesser  sac.  This  communicates  with  (2)  the  sub- 
hepatic  space  by  the  foramen  of  Winslow;  the  space 
is  bounded  above  by  the  under-surface  of  the 
liver  and  below  by  the  duodenum,  hepatic  flexure 
of  colon,  transverse  mesocolon,  right  kidney,  and 
right  costo-colic  ligament  (Fig.  85).  (3)  The 
right  subphrenic  space  between  the  diaphragm 
and  liver;  it  is  bounded  towards  the  middle  line 
by  the  falciform  and  coronary  ligaments;  below 
it  opens  into  the  subhepatic  space.  (4)  The  left 
subphrenic  space,  between  the  diaphragm  above 
and  left  lobe  of  liver  and  stomach  below;  it  is 
separated  from  the  corresponding  right  space  by 
the  falciform  ligament ;  below  it  communicates  with 

(5)  the  perisplenic  space;  this  space  is  bounded 
below  by  the  splenic  flexure  and  its  mesocolon, 
the    left    costo-colic    ligament,  and    left    kidney. 
These  five  spaces  lie  in  the  supra-omental  region 
of  the  abdomen — above  the  transverse  mesocolon. 
Below  the  transverse  mesocolon  there  are  two  spaces, 
normally  occupied   by   small   intestine ;   they   are 

(6)  the  right  i?ifra-omental,  bounded  above  by  the 
transverse  mesocolon,  below  and  to  the  left  by  the 
duodeno-jejunal  junction  and  root  of  the  mesen- 
tery ;  (7)  the  left  infra-omental,  bounded  above  by 
the   transverse    mesocolon;    it   is   separated    from 
the  right  space  by  the  duodeno-jejunal  junction 
and  fnesentery  of  the  small  bowel.     The  remaining 
space — the   eighth — lies    in   the    pelvis,    the    recto- 
uterine  in  the  female,  the  recto-vesical  in  the  male. 
Communications  between   the   supra-   and   infra- 
omental  spaces  exist  only  at  the  two  extremities 
of  the  transverse  mesocolon.     Overflow  from  the 
subhepatic  spaces  tends  to  pass  down  the  groove 
external   to  the   ascending  colon    (right  external 
paracolic  groove) ;  by  that  groove  it  reaches  the 


392 


ABDOMEN  AND  PELVIS 


[CHAP. 


iliac  fossa ;  from  the  iliac  fossa,  the  pelvic  space ; 
from  the  pelvis  it  may  mount  to  the  left  infra- 
omental  pouch,  and  from  there  the  fluid  matter 
may  make  its  way  to  the  left  external  paracolic 
groove  and  thence  to  the  perisplenic  space.  In 
this  description  the  writings  of  Barnard,  Wallace, 
Box,  Jenkins,  and  Maynard  Smith  have  been 
followed. 


I     I 

_  PERICRDIUM 


PLE/IIC  FLEXURE 
UODE/IO  JEJ.  FLEXURE 


c 

PARACOLIC  GROOVE 
ILIAC  COLON 


Fig.  85. — Showing  the  average  position  of  the  abdominal 
viscera  with  their  surface  markings.  (After  Addison.) 

A,  Sterno-ensif orm  point ;  A' A',  sterno-ensif  orm  line  :  B,  mid-epigastric 
point ;  B'B',  mid-epigastric  or  transpyloric  line ;  c,  umbilical 
point ;  C'C',  umbilical  line  ;  D,  mid-hypogastric  point ;  D'p',  mid- 
hypogastric  line  ;  E  E,  outer  border  of  the  right  and  left  rectus 
abdominis  ;  F,  Monro's  point — on  the  right  spino-umbilical  line 
at  the  outer  border  of  the  rectus  abdominis. 

Surface  markings  of  the  abdominal  vis- 
cera.— In   Fig.   85   is   shown   the   position   of   the 


XVIIl] 


VISOEROPTOSIS 


393 


abdominal  viscera  in  an  average  individual,  while 
in  Fig.  86  is  represented  the  position  assumed  by 
these  viscera  in  a  well-marked  case  of  visceroptosis 
(Gle'nard's  disease).  Study  of  such  cases,  especially 
with  the  aid  of  X-rays,  shows  the  need  of  an 
accurate  and  simple  method  of  indicating  the 
normal  position  of  the  abdominal  contents.  The 


Fig.  86. — Showing  the  position  of  the  viscera  in  the 
condition  of  visceroptosis. 

A  A,  Sternq-ensiform  line :  it  crosses  above  the  fifth  costal  cartilage  ; 
B  B,  mid-epigastric  line  ;  C  C,  umbilical  line  ;  D  D,  mid-hypo- 
gastric  line  ;  a,  pericardium  ;  6,  stomach  (greatly  elongated  and 
dilated)  ;  c,  liver ;  c',  the  lingual  or  Kiedel's  process ;  d,  duo- 
denum ;  e,  caecum  ;  /,  transverse  colon  ;  g,  rectum  ;  h,  elongated 
gastro-hepatic  omentum. 
N* 


394  ABDOMEN  AND  PELVIS  [CHAP. 

upper  limit  of  the  viscera  is  best  indicated  by  the 
sterno-ensiform  (sterno-xiphoid)  point  and  line. 
The  position  of  the  sterno-ensiform  point  is  indi- 
cated by  a  distinct  depression  under  the  insertion 
of  the  seventh  pair  of  costal  cartilages;  the  sterno- 
ensiform  line  is  drawn  transversely  on  the  body 
through  this  point  and  should  cross  the  fifth  pair 
of  costal  cartilages  if  the  thorax  is  of  normal  shape. 
The  right  dome  of  the  diaphragm,  in  the  stand- 
ing posture,  reaches  this  line;  the  left  dome 
is  \  an  inch  below  it;  in  the  supine  position 
the  domes  rise  upwards  \  an  inch.  The  central 
tendon  is  \  an  inch  below  the  sterno-ensiform 
point.  In  visceroptosis  the  domes  of  the  dia- 
phragm and  viscera  within  them  sink  downwards 
until  they  lie  1  inch  or  more  below  their  normal 
position  (Fig.  86).  The  mid-epigastric  point  is 
taken  on  the  linea  alba  half-way  between  the 
umbilical  and  sterno-ensiform  points;  the  mid- 
epigastric  line  (transpyloric  plane  of  Addison) 
crosses  the  body  at  this  point;  it  marks  the  level 
of  the  pylorus  and  pancreas,  with  the  beginning 
and  termination  of  the  duodenum  (Fig.  85).  In 
visceroptosis  the  parts  sink  until  they  reach  the 
umbilical  line  (Fig.  86).  The  umbilical  line,  drawn 
through  the  umbilicus,  usually  crosses  somewhat 
below  the  highest  point  on  the  iliac  crests ;  the 
transverse  colon  and  duodenum  cross  the  abdomen 
above  the  line,  the  bifurcation  of  the  aorta  is 
below  it.  In  visceroptosis  the  transverse  colon, 
pyloric  part  of  stomach,  and  duodenum  descend 
well  below  the  umbilical  line  (Fig.  86).  The 
mid-hypogastric  point  is  taken  on  the  linea  alba 
half-way  between  the  umbilicus  and  symphysis 
pubis;  it  lies  about  1  inch  below  the  pro- 
montory of  the  sacrum.  The  mid-hypoga-sfric 
line  crosses  the  iliac  colon  in  the  left  groin 
and  the  fundus  of  the  caecum  in  the  right.  The 
outer  border  of  the  rectus  abdominis  (linea  semi- 
lunaris)  also  serves  as  a  useful  guide;  at  the  point 
where  it  crosses  the  costal  margin  on  the  right 
side  (right  costo-rectal  point)  is  situated  the  gall 


xvm]  SUPPORTS   OF   VISCERA  395 

bladder;  on  the  left  side  the  greater  curvature  of 
the  stomach  emerges  from  the  hypogastrium  at 
this  point  (Fig.  85).  A  line  drawn  from  the 
umbilicus  to  the  right  anterior  superior  iliac  spine 
(spino-umbilical  line}  provides  a  useful  guide  to 
the  ileo-csecal  region.  Monro's  point  is  situated 
on  this  line  at  the  outer  border  of  the  rectus 
abdominis;  the  ilco-caecal  orifice  lies  to  the  right 
of  Monro's  point  immediately  below  the  spino- 
umbilical  line.  In  certain  common  pathological 
states  of  the  great  bowel,  and  in  nearly  all  cases 
of  partial  or  complete  visceroptosis,  the  ileo- 
csecal  junction  is  displaced  towards  the  pelvic 
brim. 

The  viscera  arc  maintained  in  position 
by  the  action  of  several  structures,  but  by  far  the 
chief  are  the  muscles  of  the  abdominal  wall — 
the  external  and  internal  oblique,  transversalis, 
rectus  abdominis,  diaphragm,  and  levator  ani. 
By  their  contraction  or  tonus  they  maintain  the 
viscera  firmly  pressed  together;  in  the  upright 
posture  the  weight  of  the  upper  viscera  rests  on 
the  lower  viscera.  In  rising  from  the  supine 
to  the  upright  posture  the  upper  viscera  _  and 
diaphragm  are  seen  in  the  living  body  (by  aid  of 
X-rays)  to  descend  about  ^  an  inch  or  more.  When 
the  muscles  and  belly-walls  are  cut  away,  and  the 
dead  body  raised  to  the  upright  position,  all  the 
viscera  drop  downwards  to  the  extent  of  2  inches 
or  more.  The  peritoneal  ligaments,  reflections, 
omenta,  and  mesenteries  merely  limit  the  degree 
of  movement;  the  viscera  are  freely  movable  to 
allow  the  extensive  respiratory  action  of  the  dia- 
phragm. Besides  the  peritoneal,  there  are  other 
visceral  supports  formed  by  vessels  and  their 
sheaths  of  connective  tissue,  such  as  the  attach- 
ment of  the  liver  to  the  diaphragm  by  the  in- 
ferior vena  cava,  the  kidneys  and  small  intestine 
to  the  posterior  abdominal  wall  by  their  vessels. 
It  is  only  when  the  muscles  of  the  belly-wall  are 
thrown  out  of  action  that  any  strain  or  weight 
falls  on  the  peritoneal  and  vascular  supports, 


396  ABDOMEN  AND  PELVIS  [CHAP. 

The  transport  mechanism  of  the  ali- 
mentary tract. — It  must  never  be  forgotten  that 
the  living  alimentary  tract — and  it  is  with  the 
living  tract  we  have  to  deal  in  all  clinical 
cases — represents  a  mechanism  for  the  transport 
of  food  from  the  mouth  to  the  anus,  through  a 
circuitous  route,  some  29  feet  in  length  in  the 
average  adult.  From  the  time  the  food  enters  the 
tract  until  the  residue  is  expelled,  it  is  handled, 
controlled,  and  propelled  by  the  muscular  system — 
the  longitudinal  and  circular  coats — of  the  tract; 
it  is  urged  by  a  complex  series  of  timed  opera- 
tions from  section  to  section  of  the  tract,  in 
each  of  which  certain  processes  of  digestion  and 
absorption  are  carried  on.  It  is  quite  clear  that, 
for  orderly  transport  along  such  a  busy  road, 
there  must  be  an  elaborate  signal-block  system 
such  as  railway  transport  has  made  us  familiar 
with  in  everyday  life.  When  we  look  at  such 
a  diagram  of  the  alimentary  tract  as  appears 
below  (Fig.  8V),  we  see  that  the  tract  is  divided 
into  sections.  Each  section  is  separated  from  the 
next  by  a  sphincteric  point  or  tract.  There  is, 
in  the  first  place,  the  cesophageal  section,  some 
10  inches  in  length ;  it  is  separated  from  the 
pharyngeal  tract  by  the  lower  pharyngeal  or 
upper  cesophageal  sphincter;  it  is  separated  from 
the  gastric  section  by  the  lower  cesophageal  or 
cardiac  sphincter.  At  each  of  these  sphincteric 
points  food  is  temporarily  delayed  and  regulated 
in  its  transit.  The  gastric  section  extends  from 
the  cardiac  to  the  pyloric  sphincter,  a  distance 
which  is  ever  varying  but  may  be  stated  as  being 
on  the  average  from  4  to  6  inches.  The  pyloric 
sphincter  delays  and  regulates  the  passage  of 
the  food.  Then  follows  the  duodenal  section, 
some  10  or  12  inches  long;  X-ray  observations 
-show  a  duodenal  sphincteric  mechanism  in  its 
third  or  terminal  part,  especially  active  under 
certain  pathological  conditions.  Now  comes  the 
long  ileo-jejunal  tract,  which  in  a  relaxed  state 
may  measure  25  feet,  and  a  short  time  after- 


xvm]  MECHANISM  OF  ALIMENTARY  TRAOT   397 


PHARYNGEAL 


H 

CESOPHAGEAL. 


DUODENAL 


vr 

PROXIMAL 
COLIC 


VJUUL 
RECTAL 


Fig.  87. — Diagram    to  show   the   sections  and  sphincteric 
points  in  the  alimentary  tract. 

A,  B,  C,  Peritoneal  folds  by  which  the  vagal  and  splanchnic  nerve 
fibres  pass  to  important  points  in  the  alimentary  tract. 


398  ABDOMEN  AND  PELVIS  [CHAP. 

wards,  in  a  contracted  state,  be  only  15  feet 
in  length;  this  section  ends  at  the  ileo-ccecal 
sphincter,  which  regulates  the  passage  of  the 
iliac  contents  into  the  caecum.  Next  follows  the 
proximal  colic  section — the  caecum,  appendix, 
ascending  colon,  and  proximal  third  of  the  trans- 
verse colon — where  again  there  is  a  sphincteric 
mechanism,  a  mid-colic  tract,  which  regulates  the 
passage  of  the  colic  contents  from  the  proximal 
to  the  distal  section  of  the  colon.  The  distal 
colic  section,  about  3|  feet  in  length,  and  more 
than  double  the  length  of  the  proximal  section, 
ends  at  the  recto-colic  sphincteric  tract,  at  the 
junction  of  the  pelvic  colon  and  rectum.  The 
rectum,  about  8  inches  in  length,  ends  at  the 
internal  sphincter.  It  is  clear  that  a  delay  in 
one  section  must  disturb  the  action  of  the  other 
sections;  that  is  found  to  be  the  case. 

The  musculature  of  each  of  these  sections  has, 
like  the  muscle  of  the  heart,  an  inherent  power 
of  rhythmical  contraction ;  each  section  has  its 
own  beat,  a  slow  one — that  of  the  stomach 
varies  from  6  to  8  per  minute;  the  contraction 
waves  are  slowly  conducted,  about  1  inch  per 
second.  As  in  the  heart,  the  contraction  waves 
begin  at  the  most  excitable  points;  the  most 
excitable  points  are  invariably  placed  at  the 
proximal  end  of  the  segment;  excitability  becomes 
less  as  each  section  is  descended.  Hence  the 
waves  pass  normally  towards  the  anus,  except  at 
the  mid-colic  sphincteric  tract,  where  antiperi- 
staltic  waves,  passing  towards  the  caecum,  can 
and  do  arise,  Antiperistalsis  may  be  produced 
under  abnormal  circumstances  at  any  point  in 
any  section  by  raising  the  excitability  of  that 
point. 

It  is  quite  clear  that  there  must  be  an 
elaborate  mechanism  constantly  at  work,  regu- 
lating and  harmonizing  the  action  of  the  various 
segments.  We  know,  for  example,  that  when  the 
gastric  section  passes  into  action  on  taking  food, 
a  simultaneous  action  is  set  up  in  the  distal 


xvin]  RELATIONS   OF  STOMACH  399 

ileum.  We  know,  too,  that  when  disease  of  the 
caecum,  appendix,  or  proximal  colon  is  present, 
there  is  a  stasis  in  the  lower  ileum  due  to 
the  contraction  of  the  ileo-csecal  sphincter,  and 
there  is  a  disturbed  or  retarded  action  in  the 
gastric  and  duodenal  sections.  Such  results  can  be 

Produced  experimentally  when  all  nerves  issuing 
rom  the  medulla  and  spinal  cord — the  vagi, 
dorsal  sympathetic,  and  pelvic  nerves — are  cut. 
These  reactions  are  not  brought  about  by  a  central 
but  by  a  peripheral  mechanism,  resident  in  peri- 
pheral nerve  plexuses  and  connected  ganglia, 
particularly  in  the  myenteric  (Auerbach's)  plexus, 
which  is  situated  between  the  outer  or  longitudinal 
and  inner  or  circular  coats  of  the  tract.  We 
know  that  the  central  nervous  system  can  and 
does  affect  the  motor  system  of  the  tract  through 
the  vagal,  sympathetic,  and  pelvic  efferent  nerves, 
but  they  exercise  that  power  not  directly  but 
through  the  mediation  of  the  peripheral  system 
lying  within  the  walls  of  the  tract.  With  these 
general  principles  constantly  kept  in  mind,  we 
may  now  take  up  more  profitably  the  considera- 
tion of  the  various  structures  in  a  more  strictly 
anatomical  manner. 

The  stomach. — The  relationships  of  this  organ 
are— 

Above. 
Liver,  small  omentum,  diaphragm. 


In  front. 

(From  left  to  right)  dia- 
phragm, abdominal  wall, 
liver. 


Stomach. 


Behind. 
Transverse  mesocolon, 
lesser  sac,  pancreas, 
crura,  solar  plexus,  great 
vessels,  spleen,  left  kid- 
ney, and  suprarenal. 


Below. 

Great  omentum,  small  intestines,  transverse  colon,  gastro-splenic 
omentum. 

The  oesophagus  perforates  the  diaphragm 
slightly  to  the  left  of  the  middle  line  and  ends  at 
the  cardiac  orifice  of  the  stomach,  3  to  4  inches 
deep  to  the  terminal  inch  of  the  seventh  left  costal 
cartilage.  The  pyloric  orifice,  permanently  closed 


400  ABDOMEN  AND  PELVIS  [CHAP. 

by  its  sphincter  except  when  the  contents  of  the 
stomach  are  passing  to  the  duodenum,  is  situated 
on  the  mid-epigastric  plane  and  about  1  inch  to 
the  right  of  the  linea  alba  in  the  dead  body,  but 
in  the  living,  especially  in  the  upright  posture, 
its  position  is  lower,  being  slightly  to  the  right 
of  the  linea  alba  and  about  2  inches  above  the 
umbilicus  (see  Fig.  85).  Being  situated  under  the 
quadrate  lobe  of  the  liver  and  bound  to  the  trans- 
verse fissure  (porta)  by  the  gastro-hepatic  omentum, 
the  pylorus  is  necessarily  displaced  by  enlarge- 
ment or  displacement  of  the  liver;  in  cases  of 
visceroptosis  it  may  drop  to  the  umbilical  line 
(Fig.  86).  Normally  the  lesser  curvature  is  over- 
lapped by  the  liver,  and  the  gastro-hepatic  omen- 
tum is  hidden  (Fig.  85),  but  when  the  stomach 
becomes  dilated,  elongated,  or  falls  down,  the 
lesser  curvature  and  gastro-hepatic  omentum  are 
exposed  (Fig.  86).  A  curved  line  drawn  from  the 
position  of  the  cardiac  orifice  (on  the  seventh  left 
costal  cartilage,  1  inch  from  the  sternum)  to  the 
position  of  the  pylorus  (midway  between  the  epi- 
gastric point  and  right  costal  margin)  indicates 
the  normal  position  of  the  lesser  curvature.  While 
the  lesser  curvature  is  comparatively  fixed,  owing 
to  the  attachment  of  the  gastro-hepatic  omentum, 
the  greater  curvature  is  freely  movable;  its  posi- 
tion alters  as  the  stomach  is  full  or  empty,  con- 
tracted or  relaxed.  The  variable  position  of  the 
great  curvature  as  seen  in  the  living  is  repre- 
sented in  Fig.  88  from  observations  made  by 
Dr.  A.  F.  Hurst.  When  the  patient  is  standing, 
the  great  ^  curvature  Descends  to  the  umbilicus 
or  below  it;  when  lying  down,  the  great  curva- 
ture is  an  inch  or  more  above  the  umbilicus. 
Simple  dilatation  of  the  stomach  leads  to  a  low 
position  of  the  greater  curvature  without  altering 
the  position  of  the  lesser  curvature;  in  ptosis  of 
the  stomach  both  curvatures  descend,  but  the 
greater  descends  more  owing  to  dilatation  being 
always  present  (Fig.  86).  In  ptosis  the  curvatures 
become  more  vertical  in  position  (Fig.  86). 


XVIIl] 


SHAPE   OF  THE  STOMACH 


401 


It  must  be  remembered  that  even  in  healthy 
people  the  stomach  varies  both  in  shape  and  in 
position.  In  60  young  people,  all  apparently 
in  good  health,  Dr.  Alan  Newton  found  that 
in  19  the  great  curvature  was  opposite  to  or 
above  the  umbilicus,  while  in  41  it  lay  below,  in 
some  cases  far  below,  the  umbilicus.  In  healthy 
people  the  stomach  may  be  mainly  confined  to 
the  epigastric  region  as  in  children,  or  extend 
to  the  hypogastric  region  as  is  common  in 
the  aged. 

The  shape  of  the  stomach  depends  on  many 
conditions  :  on  its  state  of  physiological  activity, 


Fig.  88. — Radiographic  outline  of  the  stomach  of  a  patient 
who    has    taken    a    bismuth-laden    diet.       (After    Dr. 

A.  F.  Hurst.') 

A,  Standing  position  ;  B,  horizontal  position. 

on  the  pressure  of  surrounding  organs,  and  on 
its  degree  of  fullness.  In  life,  its  cardiac  and 
pyloric  parts  react  differently  during  digestion; 
the  cardiac  part,  which  is  vertical  in  position 
and  constitutes  about  two-thirds  of  the  organ, 
undergoes  mainly  a  tonic,  not  a  peristaltic,  con- 
traction. The  pyloric  part,  tubular  in  shape  ant? 
horizontal  in  position,  is  the  seat  of  constant  peri- 
staltic waves  during  digestion.  These  waves  sweep 
towards  the  duodenum  along  the  pyloric  division. 
The  point  at  which  they  begin  is  often  found 
contracted  after  death,  and  this  observation  has 


402  ABDOMEN  AND  PELVIS  [CHAP. 

given  rise  to  the  opinion  that  the  cardiac  and 
pyloric  divisions  are  separated  by  a  mid-gastric 
sphincter.  When  food  is  swallowed,  it  passes  at 
once  into  the  pyloric  division,  and,  as  more  food 
is  taken,  both  divisions  of  the  stomach  fill  (Dr. 
A.  F.  Hurst  and  Dr.  A.  E.  Barclay).  The  fundus 
of  the  stomach,  lying  in  the  left  dome  of  the 
diaphragm,  always  contains  '  air  both  in  the 
resting  and  in  the  active  organ.  The  gastric 
cushion  of  air  distends  the  left  dome  of  the 
diaphragm  just  as  the  right  dome  is  cushioned 
by  the  convexity  of  the  liver.  A  gastric  cushion 
of  air  is  necessary  for  the  normal  action  of  the 
diaphragm.  The  amount  of  air  is  regulated  in 
health;  in  diseased  conditions  the  regulating 
mechanism  is  apt  to  break  down,  and  disten- 
sion results.  When  empty  the  stomach  may  be 
found  to  be  diastolic  or  systolic;  if  systolic  it  is 
usually  covered  by  the  transverse  colon,  and  does 
not  present  when  the  epigastrium  is  laid  open. 
The  two  extremities  of  the  stomach  are  its  most 
fixed  points.  The  cardiac  extremity  is  loosely 
fixed  to  the  diaphragm  by  the  oesophagus,  lax 
pericesophageal  tissue,  and  gastro-phrenic  reflec- 
tions of  peritoneum;  the  pyloric  end  is  fixed  to 
the  liver  and  posterior  abdominal  wall  by  the 
gastro-hepatic  omentum,  by  the  hepatic  branch  of 
the  cceliac  axis  and  the  tissue  surrounding  that 
vessel.  The  close  relations  of  the  stomach  to  the 
diaphragm  and  thoracic  viscera  serve  in  part 
to  explain  the  shortness  of  breath  and  possible 
palpitation  of  the  heart,  etc.,  that  may  follow 
upon  distension  of  the  organ  (Fig.  85).  The  near 
proximity  of  the  heart  to  the  stomach  is  illus- 
trated by  a  case  where  a  thorn  (of  the  Prunus 
spinosa),  \  an  inch  long,  had  been  swallowed  and 
had  then  found  its  way  through  the  diaphragm 
and  pericardium  into  the  wall  and  cavity  of  the 
right  ventricle. 

The  viscus  is  susceptible  of  enormous  dilatation 
when  the  pylorus  is  obstructed.  The  distended 
organ  may  reach  as  low  as  the  pubes. 


xvin]          WOUNDS   OF  THE   STOMACH  403 

The  stomach  rests  behind  on  the  lesser  sac  of 
the  peritoneum,  which  plays  the  part  of  a  bursa 
to  it.  Gastric  ulcers  rarely  perforate  into  the 
lesser  sac,  but  when  they  do  the  contents  can  only 
escape  by  the  foramen  of  Winslow,  and  may  not 
be  seen  when  the  abdomen  is  opened.  The  sac 
is  opened  by  incising  the  great  omentum  at  the 
greater  curvature  of  the  stomach. 

Wounds  of  the  stomach. — In  most  cases  a 
fatal  result  rapidly  follows  upon  injuries  to  the 
stomach,  for  the  contents  of  the  organ  escape 
into  the  peritoneal  cavity  and  set  up  an  acute 
peritonitis.  The  most  certainly  and  rapidly  fatal 
cases,  therefore,  are  those  in  which  the  stomach 
was  full  of  food  at  the  time  of  the  accident. 
A  small  punctured  wound  of  the  stomach  need 
not  be  followed  by  escape  of  contents,  since  the 
loosely  attached  mucous  membrane  may  escape 
from  the  wound  and  effectually  plug  it.  This  was 
illustrated  many  times  in  the  Boer  War  and  in 
the  Great  War,  the  viscus  having  been  perforated 
by  a  Mauser  bullet.  In  a  few  cases  the  belly- 
wall  in  front  of  the  stomach  has  been  wounded, 
the  viscus  has  protruded,  its  anterior  wall  has 
been  wounded  by  the  same  injury  that  penetrated 
the  parietes,  and  a  fistulous  opening  leading  into 
the  stomach  cavity  has  resulted.  The  best  ex- 
ample of  such  cases  is  afforded  by  the  well-known 
instance  of  Alexis  St.  Martin,  the  subject  of  so 
many  physiological  experiments.  In  this  man  the 
abdominal  parietes  in  front  of  the  stomach  were 
torn  away  by  a  gunshot  wound,  a  part  of  the 
anterior  wall  of  the  stomach  sloughed;  and  a  per- 
manent fistula  resulted.  Dr.  Murchison  reports 
the  case  of  a  woman  in  whom  a  gastric  fistula 
was  produced  by  the  continued  pressure  of  a  cop- 
per coin  worn  over  the  epigastric  region.  This 
coin  was  deliberately  worn  by  the  patient  in  order 
to  excite  a  lesion  that  would  arouse  the  sympathy 
of  her  friends.  The  pressure  .led  to  an  ulceration 
that  finally  opened  up  the  stomach. 

Some    remarkable    cases    have    been    recorded 


404  ABDOMEN  AND  PELVIS  [CHAP. 

where  foreign  bodies  have  been  swallowed  and 
have  lodged  in  the  stomach.  Certain  of  these 
cases  serve  to  illustrate  the  capacity  of  the 
stomach,  and  among  the  most  striking  is  an 
instance  where  the  viscus  at  death  was  found 
to  contain  31  entire  spoon-handles,  each  about 
5  inches  long,  4  half-handles,  9  nails,  half  an 
iron  shoe-heel,  a  screw,  a  button,  and  4  pebbles. 
The  whole  mass  weighed  2  Ib.  8  oz.  The  patient 
was  a  lunatic. 

Lymphatics  of  the  stomach.— The  stomach  is 
abundantly  supplied  with  lymphatics,  which  com- 
mence in  the  mucous  coat  and  form  plexuses  in 
the  submucous  and  muscular  strata,  from  which 
efferent  vessels  pass  to  glands  along  the  lesser 
and  greater  curvatures.  By  these  vessels  primary 
cancers  of  the  stomach  spread,  and  hence  their 
connexions  become  of  surgical  importance.  The 
distribution  of  the  glands  connected  with  the 
stomach  is  shown  in  Fig.  89.  The  chief  group 
— the  coronary — is  situated  near  the  cesophageal 
orifice  and  along  the  upper  part  of  the  lesser 
curvature.  The  afferent  vessels  of  this  group  are 
shown  in  Fig.  89 ;  the  efferent  vessels  pass  with  the 
coronary  artery  to  the  suprapancreatic  group 
behind  the  lesser  sac  and  near  the  origin  of  the 
coeliac  axis  from  the  aorta.  The  subpyloric  group 
is  situated  below  and  behind  the  pylorus.  It 
receives  afferent  vessels  from  glands  along  the 
greater  curvature  (right  gastro-epiploic),  and  from 
the  pylorus  and  duodenum;  its  efferent  vessels 
pass  with  the  hepatic  artery  to  the  suprapan- 
creatic group,  and  some  also  end  in  the  superior 
mesenteric  group  at  the  origin  of  the  superior 
mesenteric  artery.  The  efferent  vessels  of  the 
subpyloric  group  are  joined  by  the  lymphatics 
from  the  liver  (Fig.  89).  (Jamieson  and  Dobson.) 

Gastrotomy  and  gastrostomy.— Gastrotomy  con- 
sists in  opening  the  stomach  through  the  an- 
terior abdominal  wall  for  the  purpose  of  removing 
a  foreign  body,  for  making  an  examination,  or 
for  dealing  with  a  simple  or  malignant  ulcer; 


xvin]    GASTROTOMY  AND   GASTROSTOMY       405 

gastrostomy^,  in  opening  the  stomach  in  a  like 
situation  with  the  object  of  establishing  a  gastric 
fistula  through  which  the  patient  may  be  fed  in 
cases  where  the  gullet  is  occluded  by  disease.  The 
uncovered  part  of  the  stomach,  accessible  in  these 
operations,  is  represented  by  a  triangular  area, 
bounded  on  the  right  by  the  edge  of  the  liver,  on 


CESGFH, 


SPLENIC  ART 


Fig.  89. — The  groups  of  lymphatic  glands  connected 
with  the  stomach.  (Prof.  J.  K.  Jamieson  and  Mr. 
J.  F.  Dobson.) 

the  left  by  the  cartilages  of  the  eighth  and  ninth 
ribs,  and  below  by  a  horizontal  line  passing 
between  the  tips  of  the  tenth  costal  cartilages 
(Fig.  85).  The  incision  in  these  operations  must 
be  situated  in  this  triangle,  and  may  be  made 
either  parallel  to  and  about  two  fingers'  breadth 
from  the  free  border  of  the  costse,  or  along  the  left 


406  ABDOMEN  AND  PELVIS  [CHAP. 

semilunar  line.  In  the  former  incision  the  three 
flat  muscles  of  the  abdomen  are  cut  through. 

The  pylorus  is  normally  in  a  closed  state, 
and  should,  when  open,  be  capable  of  taking 
the  forefinger.  In  spite  of  the  narrowness  of 
the  pylorus,  large  substances  that  have  been 
swallowed  have  been  passed  by  the  anus  without 
trouble.  Among  these  mayv  be  noted  a  metal 
pencil-case,  4|  inches  long,  10  oz.  of  garden 
nails,  and  fragments  of  crockery-ware,  swallowed 
by  a  lunatic;  a  fork,  a  door-key,  and  other 
strange  bodies.  Needles  and  similar  sharp  sub- 
stances that  have  been  swallowed  have  travelled 
out  of  the  stomach  or  bowels  and  have  found 
their  way  to  the  surface  at  various  points  in 
the  body.  In  a  patient  under  my  (F.  T.'s)  care 
at  the  London  Hospital,  a  needle  swallowed  some 
months  previously  was  extracted  from  beneath  the 
skin,  near  the  groin.  In  a  case  reported  in  the 
Lancet  a  needle  was  extracted  from  the  middle  of 
the  thigh,  six  months  after  it  had  been  swallowed ; 
and  like  instances  are  recorded  elsewhere. 

Hypertrophy  may  take  place  in  the  pyloric 
sphincter,  leading  to  the  functional  stenosis  of  the 
orifice.  It  occurs  soon  after  birth,  and  its  cause 
has  to  be  sought  for  in  the  reflex  mechanism  which 
regulates  the  pylorus.  It  is  not  easy  to  tell  when 
the  sphincter  is  hypertrophied,  because  the  thick- 
ness of  the  circular  layer  depends  on  the  degree 
of  contraction  at  death.  In  a  normal  child  of 
3  months  the  circular  layer  of  the  sphincter  varies 
from  1  to  2  mm,  in  thickness  at  the  pylorus,  and 
extends  along  the  pyloric  canal  for  25  mm.  (1 
inch)  :  if  the  thickness  is  over  3  mm.  the  sr>hincter 
may  be  regarded  as  hypertrophied  (L.  Mackey). 
Relaxation  of  the  sphincter  normally  follows  when 
the  chyme  expelled  from  the  stomach  has  been 
neutralized  in  the  duodenum.  An  acid  condition 
of  the  duodenal  contents  inhibits  sphincteric 
relaxation. 

Resection  of  the  pylorus.— The  pylorus  is  fre- 
quently the  seat  of  cancer.  As  a  means  of  reliev- 


xvin]  GASTREGTOMY  407 

ing  the  patient,  the  whole  of  the  diseased  pyloric 
region  has  been  removed,  and  the  divided  ends 
of  the  stomach  and  duodenum  united  by  sutures. 
The  situation  of  the  cancerous  pylorus  within  the 
abdomen  varies  considerably,  as  the  diseased  part 
is  very  apt  to  shift  its  position.  It  is  often  found 
to  have  sunk  down  by  its  weight  to  a  point  below 
the  umbilicus,  and  to  have  contracted  adhesions 
to  adjacent  organs.  The  diseased  part  has  to  be 
isolated  and  the  omental  connexions  of  the  right 
end  of  the  stomach  freely  divided.  The  vessels  that 
are  almost  certainly  divided  are  the  pyloric,  the 
gastro-epiploica  dextra,  and  the  gastro-duodenal. 

Qastrectomy.  —  Considerable  portions  of  the 
stomach  have  been  excited  in  cases  of  cancer,  and 
the  entire  organ  has  been  removed  (total  gastrec- 
tomy)  for  the  same  cause.  Up  to  the  time  of 
writing,  some  fifteen  examples  of  this  operation 
have  been  recorded,  with  more  or  less  immediate 
death  in  five.  In  Schlatter's  first  case  of  gas- 
trectomy,  performed  in  1897,  the  patient  died  in 
fourteen  months  from  secondary  deposits.  In  a 
case  operated  on  by  Sir  Berkeley  Moynihan  the 
patient  survived  the  operation  for  six  years 
and  was  able  to  lead  a  normal  life.  Kicord 
published  a  case  in  which  he  removed  the  whole 
stomach,  the  first  piece  of  the  duodenum,  and 
part  of  the  pancreas.  The  patient  was  alive  and 
well  eleven  months  after  the  operation  (Gaz.  des 
Hopitaux,  March  22nd,  1900).  There  is  difficulty 
in  uniting  the  gullet  to  the  small  intestine;  both 
vagi  nerves  are  divided  as  they  emerge  through 
the  diaphragm,  and  the  solar  plexus  is  apt  to  be 
roughly  handled. 

Other  operations  on  the  stomach. — Many  other 
operations  are  performed  upon  the  stomach  which 
call  merely  for  mention  in  this  place.  One  of 
the  most  useful  and  the  most  frequently  per- 
formed is  gastro-jejunostomy,  where  an  opening 
(or  stoma)  is  made  between  the  stomach  and 
the  upper  part  of  the  jejunum.  In  this  opera- 
tion the  transverse  mcsocolon  is  opened  in  order 


408  ABDOMEN  AND  PELVIS     .         [CHAP. 

that  the  bowel  may  be  applied  to  the  pos- 
terior aspect  of  the  stomach.  In  making  the 
opening  the  middle  colic  artery  and  its  larger 
branches  are  to  be  avoided.  The  operation  is 
performed  in  cases  of  stenosis  of  the  pylorus, 
in  cases  of  dilatation  of  the  stomach  without 
much  stenosis,  in  certain  examples  of  ulcer,  and 
in  many  other  conditions.  In  the  operation  of 
pyloroplasty  a  non-malignant  stricture  of  the 
pylorus  is  divided  and  the  pyloric  passage  thus 
made  free.  In  gastroplication  certain  conditions 
of  dilated  stomach  are  dealt  with  by  taking  in 
a  fold  or  pleat  in  the  stomach  wall  and  thus 
lessening  its  capacity. 

Small  intestine.*  —  The  average  length  of 
the  small  intestine  in  the  adult  is  22j  feet,  the 
extremes  being  30  feet  and  15  feet,  the  length,  to 
a  considerable  extent,  depending  on  the  degree 
of  contraction  of  the  longitudinal  muscular  coat. 
In  the  foetus,  at  full  term,  the  lesser  bowel  mea- 
sures about  9^  feet.  It  is  roughly  reckoned  that 
the  first  8  or  9  feet  of  the  adult  bowel  belong  to 
the  jejunum,  and  the  remaining  12  or  13  feet  to  the 
ileum.  The  division  into  jejunum  and  ileum  is 
quite  arbitrary.  There  is  no  one  point  where  it 
can  be  said  that  the  jejunum  ends  and  the  ileum 
commences.  When  the  small  intestines  are  ex- 
posed by  accident  or  operation,  it  is  often  diffi- 
cult, especially  when  there  is  abdominal  disease, 
to  recognize  the  upper  from  the  lower  part  of  the 
gut.  It  may  be  noted,  however,  that  the  jejunum 
is  wider  than  the  ileum  (its  diameter  being  \  of  an 
inch  greater  than  that  of  the  ileum),  and  that  its 
coats  are  thicker  and  more  vascular.  If  the  gut 
be  empty,  and  can  be  rendered  translucent  by 
being  held  against  a  light,  the  lines  of  the  valvulse 
conniventes  can  be  well  seen.  These  folds  are 
large  and  numerous  in  the  jejunum,  but  become 
small  and  scanty  in  the  upper  ileum,  and  are 
wanting  in  the  lower  third  of  that  bowel. 

*  The  account  of  the   intestines   is   based  upon  the  author's  work 
"On  the  Intestinal  Canal  and  Peritoneum  in  Man."    London,  1885. 


xvin]  THE   SMALL  INTESTINE  409 

The  coils  of  small  intestine  occupy  no  cer- 
tain position  in  the  abdomen.  In  the  foetus,  and 
during  the  earliest  part  of  extra-uterine  life,  the 
bulk  of  the  small  intestine  is  placed  to  the  left 
of  the  middle  line.  This  is  on  account  of  ;the  re- 
latively large  size  of  the  liver,  to  the  weight  of 
which  the  lesser  bowel  no  doubt  acts  as  a  counter- 
poise. In  the  majority  of  adult  bodies  the  small 
intestine  is  disposed  in  an  irregularly  curved 
manner  from  left  to  right.  The  gut,  starting 
from  the  duodenum,  will  first  occupy  the  contigu- 
ous parts  of  the  left  side  of  the  epigastric  and 
umbilical  regions;  the  coils  then  fill  some  part  of 
the  left  hypochondriac  and  lumbar  regions;  they 
now  commonly  descend  into  the  pelvis,  reappear 
in  the  left  iliac  quarter,  and  then  occupy  in  order 
the  hypogastric,  lower  umbilical,  right  lumbar, 
and  right  iliac  regions.  Before  reaching  the  right 
iliac  region  they  commonly  descend  again  into 
the  pelvis. 

Much  interest  attaches  to  the  coils  of  small 
intestine  that  are  found  in  the  pelvis.  These  are 
the  coils  that  are  apt  to  become  involved  and  ad- 
herent in  cases  of  pelvic  peritonitis,  and  that 
would  probably  form  the  protrusion  in  most  cases 
of  obturator,  sciatic,  and  pudendal  hernia.  No 
small  intestine  occupies  the  fcetal  pelvis.  The 
amount  found  in  the  adult  pelvis  depends  mainly 
upon  the  state  of  distension  of  the  bladder  and 
rectum,  and  upon  the  position  of  the  pelvic 
colon.  The  coils  that  are  most  usually  found 
in  this  position  belong  to  the  terminal  part  of  the 
ileum,  and  to  that  part  of  the  intestine  that  has 
been  already  alluded  to  as  possessing  the  longest 
mesentery  (p.  389).  The  ileum  is  the  part  of 
the  intestine  that  is  most  frequently  found  in 
inguinal  and  femoral  hernise.  It  is  also  the  part 
most  usually  involved  in  cases  of  strangulation  by 
internal  bands,  by  holes  in  the  mesentery,  etc. 

Of  all  the  viscera,  the  small  intestines  are  the 
most  exposed  to  injury,  and  at  the  same  time  it 
must  be  noted  that  by  their  elasticity,  and  by  the 


410  ABDOMEN  AND  PELVIS  [CHAP. 

ease  with  which  their  coils  slide  over  one  another 
and  so  elude  the  effects  of  pressure,  they  are  the 
best  adapted  to  meet  such  injuries  as  contusions 
and  the  like.  A  minute  punctured  wound  of  the 
small  gut  does  not  lead  to  extravasation  of  con- 
tents. The  muscular  coat  contracts  and  closes  the 
little  opening.  Thus,  in  excessive  tympanites  the 
bowels  are  often  freely  punctured  in  many  places 
with  a  fine  capillary  trocar,  to  allow  the  gas 
to  escape,  without  any  evil  resulting.  A  case  of 
intestinal  obstruction  of  sixteen  weeks'  duration 
is  reported,  in  which  the  abdomen  was  punctured 
150  times  (Boston  Med.  Journ.).  If  the  wound 
be  a  little  larger  the  loose  mucous  membrane  be- 
comes everted  or  protruded  through  the  wound 
and  ^effectually  plugs  it.  Gross  observed  ^that  a 
longitudinal  cut  in  the  small  bowel  2^  lines  in 
length  was  immediately  reduced  to  a  wround  If 
lines  in  length  by  muscular  contraction,  and  that 
the  eversion  of  the  ^mucous  membrane  in  addi- 
tion to  this  contraction  entirely  sealed  the  open- 
ing. Even  the  opening  made  in  the  intestine — 
for  example,  in  the  jejunum — by  the  penetration 
of  a  Mauser  bullet  may  be  attended  by  no  escape 
of  contents.  A  contracted  empty  piece  of  bowel 
becomes  nearly  twice  as  long  when  distended. 

Owing  to  the  greater  power  of  the  circular 
layer  of  muscle  a  longitudinal  wound  gapes  more 
than  a  transverse  wound,  and,  in  consequence  of 
the  greater  muscular  development  of  the  jejunum, 
wounds  of  that  part  gape  more  than  do  those  of 
the  t  ileum.  Transverse  wounds  gape  most  when 
inflicted  across  the  free  border  of  the  gut,  since 
in  that  place  the  longitudinal  muscular  fibres 
are  thickest. 

In  one  remarkable  case  a  man  was  stabbed  in 
the  belly.  It  was  subsequently  found  that  there 
was  a  small  puncture  in  the  ileum,  which  had  been 
plugged  by  the  mucous  membrane  and  further 
secured  by  recent  lymph.  The  man  did  well 
until  the  fourth  day,  when  he  died  somewhat 
suddenly.  It  was  then  found  that  an  intestinal 


xvm]  MEGKEL'S   DIVERTIGULUM  411 

worm  (Ascaris  lumbricoides)  had  worked  its  way 
through  the  wound,  breaking  down  the  adhesions, 
and  had  escaped  into  the  peritoneal  cavity.  Ex- 
travasation followed,  and  thus  the  worm  was  the 
cause  of  the  man's  death. 

The  calibre  of  any  portion  of  the  small  in- 
testine depends  mainly  upon  the  condition  of  its 
muscular  wall.  The  tube  may  become  much  con- 
tracted when  empty.  On  the  other  hand,  the 
muscular  coats  of  a  loop,  or  part  of  a  loop, 
of  bowel  may  pass  into  a  state  of  permanent 
contraction  or  intestinal  spasm,  giving  rise  to 
symptoms  of  intestinal  obstruction.  Or  a  similar 
result  may  arise  from  an  opposite  condition — 
that  of  paralysis.  If  a  piece  of  bowel  is  injured 
or  cut  (as  may  be  necessary)  in  resection  of  the 
intestine,  or  is  involved  in  a  localized  inflam- 
mation or  peritonitis,  it  passes  into  a  state  of 
paralysis  (paralytic  ileus  of  Handley)  and  hence 
is  unable  to  pass  on  the  alimentary  contents, 
which,  therefore,  collect  and  distend  the  segment 
of  bowel  proximal  to  the  seat  of  injury  or 
peritonitis. 

Meckel's  diverticulurn. —  From  1  to  4  feet  from 
the  end  of  the  ileum  is  sometimes  seen  a  diver- 
ticulum (Meckel's)  (Fig.  90)  which  represents  the 
remains  of  the  vitello-intestinal  duct  (p.  355). 
It  may  be  expected  in^2  per  cent,  of  the  bodies 
examined.  This  diverticulum  usually  exists  as  a 
tube  of  the  same  structure  as  the  intestine.  Its 
length  varies.  It  may  sometimes  extend  as  a 
patent  tube  as  far  as  the  umbilicus.  It  is  more 
often  but  a  few  inches  long,  and  may  then  end 
in  a  free  conical  or  globular  extremity,  or  in  a 
fibrous  cord.  This  diverticulum  may  cause  in- 
testinal obstruction  in  many  ways.  Its  end  may 
contract  adhesions,  and  beneath  the  bridge  thus 
formed  a  loop  of  bowel  may  be  strangled.  It  may 
twist  itself  about  a  piece  of  intestine  so  as  to 
form  a  knot  round  it.  In  more  than  one  case 
it  has  been  found  in  an  external  hernia.  It 
may  become  invaginated  and  start  an  intussus- 


412 


ABDOMEN  AND  PELVIS 


[CHAP. 


ception  of  the  bowel.  The  lumen  of  the  gut  is 
often  considerably  diminished  at  or  near  the  site 
of  the  diyerticulum,  and  at  this  narrowing  in- 
tussusception of  the  bowel  may  commence. 

A  loop  of  bowel  may  be  strangulated  over 
the  remains  of  a  patent  vitello-intestinal  duct 
(Fig.  90).  The  duct,  if  complete,  ends  at  the 
umbilicus.  The  artery  of  the  yolk-sac  may  also 
persist,  and  form  a  cord  between  the  mesentery 
of  the  ileum  and  the  umbilicus,  and  over  this 
a  loop  of  bowel  may  become  strangulated.  A 


VlTELLINE    DUCT 


C/ECUM 


APPENDIX 


Fig.  90. — To  show  MeckePs  diverticulum,  the  remains  of 
the  vitello-intestinal  duct,  and  of  the  artery  to  the 
yolk-sac. 

short  cord  may  pass  from  the  mesentery  of  the 
ileum  to  the  fundus  of  the  diverticulum,  and 
between  this  and  the  diverticulum  a  knuckle  of 
bowel  may  become  incarcerated.  Such  a  cord  may 
arise  in  three  ways  :  (1)  from  the  proximal  part 
of  the  artery  of  the  yolk-sac,  (2)  from  the  free 
border  of  a  mesentery  with  which  the  diverti- 
culum may  be  provided,  and  (3)  by  the  elongation 
of  an  inflammatory  adhesion  between  the  apex  of 
the  diverticulum  and  the  mesentery  (Fig.  90). 


xvm]  THE   DUODENUM  413 

Duodenum     and     fossa      duodeno  =  jejunalis, — 

The  first  portion  of  the  duodenum  is  nearly 
horizontal.  It  measures  about  2  inches  in 
length  and  passes  backwards  from  the  pylorus  to 
near  the  upper  end  of  the  right  kidney.  The 
second  portion,  about  3  inches  in  length,  descends 
vertically  in  front  of  the  inner  border  of  the 
right  kidney  to  the  level  of  the  third  lumbar 
vertebra.  The  third  portion,  some  5  inches  in 
length,  crosses  from  right  to  left  in  front  of  the 
third  vertebra,  and  then  ascends  for  a  short  dis- 
tance on  the  surface  of  the  left  psoas  muscle,  to 
end  in  the  jejunum  to  the  left  of  the  second 
lumbar  vertebra  (Fig.  85,  p.  392).  The  first  por- 
tion, which  is  movable,  is  invested  by  peritoneum 
in  the  same  manner  as  the  stomach.  The  second 
part  is  covered  by  peritoneum  in  front  only,  ex- 
cept at  the  spot  where  it  is  crossed  by  the  trans- 
verse colon.  The  third  part  is  also  covered  by 
peritoneum  on  its  anterior  aspect  only,  this  mem- 
brane being,  however,  free  of  the  gut  where  the 
superior  mesenteric  vessels  cross  it.  A  sphinc- 
teric  constriction  is  usually  found  near  the 
termination  of  the  third  stage. 

The  end  of  the  duodenum,  the  duodeno- 
jejunal  bend,  is  very  firmly  held  in  place  by  a 
band  of  fibro-muscular  tissue  which  descends  upon 
it  from  the  right  crus  of  the  diaphragm  and  the 
tissue  about  the  coeliac  axis.  This  band  is  called 
the  suspensory  muscle  of  the  duodenum  (Treitz).  It 
serves  also  to  support  the  mesentery.  In  ptosis  of 
the  viscera  the  neck  of  the  pancreas  and  duodeno- 
jejunal  bend  are  the  least  displaced  parts  be- 
cause of  their  attachment  to  the  posterior  wall  by 
the  fibrous  tissue  round  the  coeliac  axis  and  origin 
of  the  superior  mesenteric  artery.  All  sections  of 
the  duodenum  have  been  ruptured  by  violence. 
Owing  to  its  large  non-peritoneal  surface,  the 
bowel,  if  approached  from  behind,  may  be 
wounded  without  opening  the  peritoneum. 

Brunner's  glands  occur  in  the  first  stage  of  the 
duodenum;  their  secretion  probably  protects  this 


414  ABDOMEN  AND  PELVIS  [CHAP. 

part  of  the  gut  against  the  acid  chyme  which 
is  only  neutralized  as  it  reaches  the  second  stage. 
It  is  probably  because  of  the  nature  of  its  con- 
tents that  the  first  stage  of  the  duodenum  is  so 
frequently  the  site  of  ulcerationj  over  90  per  cent, 
of  duodenal  ulcers  occur  in  the  first  stage  (Collin). 
The  ulcer  may  perforate  and  the  contents  escape 
into  the  subhepatic  space,  or  adhesions  may  form 
to  surrounding  organs — the  gall-bladder,  the  liver, 
the  head  of  the  pancreas,  the  right  kidney,  or  the 
hepatic  flexure  of  the  colon. 

Very  frequently  small  diverticula  of  the  mu- 
cous membrane  are  formed  at  the  point  where 
the  common  bile-duct  perforates  the  muscle 
coat  of  the  duodenum.  They  are  often  large 
enough  to  take  the  first  joint  of  the  forefinger, 
and  occur  especially  in  cases  of  ptosis  of  the 
viscera.  In  the  newly  born  a  complete  occlusion 
of  the  duodenum  may  be  found  just  above  the 
entrance  of  the  common  bile-duct. 

On  the  left  side  of  the  terminal  part  of  the 
duodenum  is  the  duodeno=jejunal  fossa.  Normally 
it  is  occupied  or  filled  by  the  convexity  of  the 
terminal  part  of  the  duodenum,  to  which  it  serves 
as  a  bursa.  The  suspensory  ligament  or  fold 
forms  its  upper  crescent  or  border,  its  lower 
crescent  being  formed  by  another  fold,  the 
duodenal  (Fig.  91).  The  fossa  is  only  apparent 
when  the  duodenum  is  artificially  displaced.  The 
inferior  mesenteric  vein  ascends  near  the  left 
margin  of  the  pocket  (Fig.  91).  This  fossa  is 
the  anatomical  cause  of  mesenteric,  mesocolic, 
mesogastric,  or  retroperitoneal  hernia.  The  com- 
mencement of  the  jejunum  presses  into  the  fossa, 
enlarges  its  cavity,  and  ultimately  separates  the 
peritoneum  from  its  posterior  attachments.  It 
may  spread  in  one  or  in  all  of  three  directions : 
to  the  right,  behind  the  duodenum;  to  the  left, 
behind  the  inferior  mesenteric  vein;  or  upwards, 
behind  the  suspensory  ligament  and  root  of  the 
transverse  mesocolon.  More  and  more  of  the 
small  intestine  passes  into  the  increasing  pouch, 


XVIIl] 


ENTEROTOMY 


415 


until  at  last,  as  in  the  case  reported  by  Sir 
Astley  Cooper  and  in  many  others,  nearly  the 
whole  of  the  small  intestine  may  be  found  lodged 
in  an  enormous  median  retroperitoneal  sac,  the 
mouth  of  which  is.  the  orifice  of  the  fossa  duodeno- 
jejunalis.  The  duodenum  can  be  seen  to  enter 
the  sac  and  the  end  of  the  ileum  to  leave  it. 
The  sac  usually  extends  downwards  on  the  left 


DUODENAL 


Fig.  91. — The  fossa  duodeno-jejunalis. 

side,  and  may  reach  the  promontory  of  the  sacrum. 
In  such  hernia  obstruction  is  apt  to  occur. 

Operations  on  the  small  intestine.— Enterotomy 
is  the  operation  of  ^  opening  the  small  intestine 
above  some  obstruction  that  threatens  to  be  fatal 
or  insuperable.  A  knuckle  of  bowel,  above  the 
obstruction,  is  secured  to  the  wound  in  the  ab- 
dominal wall,  and  opened  The  small  intestine 
has  ^also  been  opened  to  remove  impacted  foreign 
bodies  and  large  gall-stones.  In  such  cases  the 
intestinal  wound  is  closed  immediately. 


416  ABDOMEN  AND  PELVIS  [CHAP. 

Enter -ectomy. — Parts  of  the  small  intestine  have 
been  resected  with  success  for  various  diseased 
conditions.  In  one  case  more  than  two  yards  of 
the  small  intestine  were  eut  away  on  account  of 
multiple  stricture.  The  patient,  a  young  woman, 
made  an  excellent  recovery.  Resections  have  also 
been  successfully  performed  in  cases  of  bullet 
wound  or  stab  involving  the  lesser  bowel,  and  in 
other  injuries.  Tumours  of  the  gut  have  been 
removed  by  a  partial  resection.  Non-malignant 
strictures  of  the  bowel  have  been  treated  by  in- 
cision and  dilatation.  The  bowel  above  an  ob- 
struction has  been  connected  to  the  bowel  below 
an  obstruction  by  the  operation  called  intestinal 
anastomosis  or  short-circuiting. 

Experience  shows  that  if  leakage  occurs  after 
resection  or  suture  of  intestine  it  will  most  likely 
occur  along  the  attachment  of  the  mesentery. 
This  circumstance  is  thus  explained  by  Mr.  An- 
derson :  The  two  layers  of  the  mesentery  diverge 
as  they  approach  the  bowel,  and  so  leave  a  tri- 
angular space,  the  base  of  which,  averaging  about 
^fiths  of  an  inch  in  width,  is  formed  by  the  un- 
covered muscular  tissue.  It  is  the  existence  of 
this  bare  piece  of  intestine  that  renders  adjust- 
ment of  the  serous  coat  at  the  attachment  of  the 
mesentery  a  matter  of  some  difficulty. 

Ileo-caecal  region.— The  csecum  reaches  only 
a  moderate  development  in  man,  as  also  in  the 
carnivora.  In  herbivorous  animals  it  is  of  great 
size,  and  appears  to  serve  as  a  reservoir  for 
the  elaboration  and  absorption  of  food.  The 
appendix,  which  represents  a  specialized  part  of 
the  csecum,  is  as  well  developed  in  the  newly 
born  child  as  in  the  young  of  anthropoid  apes. 
In  the  human  foetus  it  can  be  seen  to  be  but 
the  narrowed  extremity  _of  the  caecum.  The 
foetal  type  of  csecum,  which  is  very  character- 
istic^  may  persist  throughout  life.  In  a  large  pro- 
portion of  people  the  appendix  tends  to  become 
smaller  or  atrophied  as  adult  years  are  reached, 
probably  because  our  modern  diet  makes  only  a 


xvm]  THE   O^GUM  417 

slight  call  on  its  activity.  It  is  very  frequently 
the  seat  of  disease,  and  it  is  worthy  of  note  that 
such  disease  tends  to  cause  the  entire  obliteration 
of  the  part  (as  after  many  forms  of  so-called 
appendicitis). 

It  must  be  understood  that  the  term  ccccum  is 
applied  to  that  part  of  the  colon  which  lies  below 
the  entrance  of  the  ileum.  The  average  breadth 
of  the  adult  caecum  is  3  inches,  its  average  length 
(vertical  measurement)  2^  inches.  These  measure- 
ments apply  to  the  organ  as  seen  in  the  cadaver ; 
in  the  living  it  is  constantly  changing  its  shape 
according  to  its  state  of  physiological  activity. 
The  caecum  normally  contains  gas,  and  gives  a 
high,  tympanitic  note  on  percussion;  Glenard 
found  that  in  cases  of  ptosis  of  the  viscera  it  was 
often  contracted,  and  when  palpated  had  the 
consistency  of  a  sausage. 

The  caecum  is  usually  lodged  in  the  right  iliac 
fossa,  and  is  so  placed  that  its  apex  corresponds 
with  a  point  a  little  to  the  inner  side  of  the 
middle  of  the  inguinal  ligament.  When  distended 
with  gas  or  faecal  contents  it  occupies  the  whole 
of  the  right  iliac  fossa.  The  ileo-caecal  orifice  is 
situated  immediately  below  the  spino-umbilical 
line  and  externally  to  Monro's  point  (see  Fig.  85, 
p.  392)^ 

A  slightly  distended  caecum  so  located  may  be 
emptied  by  flexing  the  thigh  upon  the  abdomen. 
The  caecum  is  entirely  invested  by  peritoneum, 
although  a  portion  of  its  ^posterior  surface  is 
occasionally  in  connexion  with  the  areolar  tissue 
of  the  iliac  fossa.  The  peritoneum  is  usually 
reflected  from  the  commencement  of  the  ascending 
colon  on  to  the  posterior  parietes  below  the  level 
of  the  iliac  crest.  A  mobile  caecum  may  hang 
over  the  pelvic  brim,  or  occupy  the  pelvis,  or 
even  find  its  way  into  an  inguinal  hernia  of  the 
left  side.  The  mobility  of  the  caecum  can  be 
tested  by  deep  palpation  when  it  is  laden  with  a 
bismuth  meal  and  examined  by  the  aid  of  X-rays. 
The  caecum  is  not  infrequently  found  in  an 
o 


418  ABDOMEN  AND  PELVIS  [CHAP. 

inguinal  or  femoral  hernia  of  the  right  side  (csecal 
hernia).  Such  herniae  are,  except  in  a  few  rare 
instances,  provided  with  a  proper  and  complete 
peritoneal  sac.  Foreign  bodies  that  have  been 
swallowed  are  very  apt  to  lodge  in  the  caecum, 
and  in  that  situation  may  cause  ulceration  and 
even  perforation  of  the  bowel,  producing  one 
form  of  typhlitis.  In  cases  of  fsecal  retention, 
also,  the  largest  accumulation  of  faecal  matter 
is  very  usually  met  with  in  the  caecum,  and 
upon  that  part  of  the  bowel  when  distension  is 
extreme  the  greatest  strain  usually  comes.  Solitary 
follicles  are  numerous  in  the  mucous  membrane 
of  the  caecum,  especially  near  the  ileo-caecal  orifice. 
Intestinal  concretions  also  are  not  uncommon  in 
this  part. 

Three  kinds  of  movement  occur  in  the  caecum  : 
(1)  a  churning  movement,  which  has  been  ob- 
served to  commence  within  an  hour  of  taking 
food;  (2)  antiperistaltic  movements,  which  begin 
in  the  colon  and  end  in  the  caecum  (see  p.  398); 
(3)  propulsive  or  emptying  movements.  Water  is 
absorbed  and  the  faeces  commence  to  assume  a  solid 
consistency  as  they  reach  the  transverse  colon. 
The  ileo-caecal  orifice  is  guarded  by  a  muscular 
sphincter  (ileo-ccecal  sphincter} ;  it  is  innervated 
by  the  sympathetic  system  and  regulates  the 
escape  of  chyme  from  the  ileum  (Elliot  and  B. 
Smith);  Sir  William  Macewen  has  seen  it  ^n 
action  in  the  case  of  a  soldier  in  whom  a  wide 
caecal  fistula  resulted  from  a  gunshot  injury.  The 
same  observer  has  also  seen  a  secretion  escaping 
from  the  mouth  of  the  appendix,  which  is  situated 
about  1  inch  below  the  ileo-caecal  orifice.  In 
certain  conditions,  as  Dr.  James  Case  was  the 
first  to  observe,  the  reflexes  which  regulate  the 
ileo-caecal  sphincter  no  longer  act,  and  the  orifice 
then  becomes  incompetent,  allowing  the  contents 
of  the  caecum  to  regurgitate  into  the  ileum. 

The  appendix  varies  in  length.  Its  average 
measurement  in  the  adult  is  4  inches,  ^the  extremes 
being  1  inch  and  6  inches.  Its  position  is  con- 


xvm]  THE   APPENBIX  419 

tinually  varying,  although,  as  a  rule,  it  is  seen  to 
lie  behind  the  end  of  the  ileum  and  its  mesentery, 
and  to  point  in  the  direction  of  the  spleen.  It 
frequently  also  lies  behind  the  caecum;  it  may 
be  found  embedded  in  the  ascending  mesocolon. 
In  such  cases  the  appendix  has  been  pushed 
behind  the  caecum  and  caught  in  the  mesocolon 
during  the  later  months  of  foetal  life,  when  the 
caecum  migrates  from  the  neighbourhood  of  the 
liver  to  the  right  iliac  fossa.  The  appendix  may 
hang  within  the  pelvis  and,  in  inflammatory  con- 
ditions, contract  adhesions  to  the  ovary  or  other 


ILEO-COLIC  FOSSA 


COLON-   w.    _    MIII-*  '.m,      -*     ^ 

-  BLOODLESS  TOLQ 


RETRO  CAECAU  FOSSA 

ILEO-CACCAL  FOSSA 

Fig.  92.— The  peritoneal  fossae  of  the  ileo-caecal  region. 

pelvic  structures.  An  inflamed  appendix  has  been 
found  adherent  to  the  liver,  and  another  in  the 
left  iliac  fossa.  It  has  made  its  way  down  both 
the  right  and  the  left  inguinal  canals.  The  tip 
of  the  process  may  adhere  to  a  neighbouring 
peritoneal  surface,  and  thus  form  a  "band," 
beneath  which  a  piece  of  small  intestine  may  be 
strangulated. 

The  mesentery  of  the  appendix  (Fig.  93),  which 
contains  an  artery  derived  from  the  ileo-colic, 
may  be  so  short  as  to  produce  kinks  in  the 
appendix.  The  mucous  lining  is  so  crowded  with 
solitary  lymphoid  follicles  as  almost  to  occlude 


420 


ABDOMEN  AND  PELVIS 


[CHAP. 


its  lumen.  Like  other  lymphoid  structures,  these 
follicles  begin  to  atrophy  soon  after  adult  life 
is  reached.  In  some  forms  of  appendicitis  these 
follicles  are  involved.  In  patients  fed  with  a 
bismuth  meal  the  shadow  of  the  appendix  can 
usually  be  distinguished  (40,  per  cent,  of  indi- 
viduals, Barclay;  80  per  cent.,  Case).  As  with  the 
rest  of  the  alimentary  tract,  its  musculature 
undergoes  a  slow  rhythmical  peristaltic  movement 
by  which,  if  the  lumen  be  still  patent,  the  csecal 


.EO-COLIG  VESSELS 


ASCEND.  COLON 


SENTERY    OF    APPENDIX 


Fig.  93. — Course  of   the   lymphatics   of   the  caecum, 
appendix,  and  colon.       (After  Jamieson  and  Dobson.) 

contents  are  slowly  introduced  and  extruded.  Its 
function  remains  unknown.  It  may  be  necessary 
to  palpate  and  displace  the  caecum  before  the 
shadow  of  the  appendix  is  seen. 

Lymphatics  of  the  caecum  and  appendix  (Fig. 
93). — Since  in  inflammation  of  the  appendix 
infection  spreads  chiefly  by  its  lymphatics,  the 
arrangement  of  this  system  is  of  surgical  im- 
portance. As  in  other  parts  of  the  alimentary 
canal,  there  are  three  plexuses  of  lymphatics  : 
(1)  a  submucous,  which  receives  the  lymph  from 


xviii]  INTUSSUSCEPTION  421 

the  mucous  membrane;  (2)  an  intermuscular 
plexus;  (3)  a  subserous  plexus.  All  three  are  in 
the  freest  communication.  The  lymphoid  follicles 
are  situated  in  submucous  lymph-spaces ;  at  breaks 
in  the  muscular  coat  the  submucous  and  subserous 
plexuses  are  in  direct  continuity ;  hence  infection 
may  readily  spread  to  the  peritoneal  coat,  setting 
up  peritonitis.  The  efferent  vessels  pass  chiefly 
into  the  meso-appendix,  where  one  or  more  glands 
may  occur,  but  most  of  the  efferent  vessels  pass 
to  the  ileo-.colic  group  of  glands  situated  in  the 
ileo-colic  angle  (Fig.  93).  This  group  also  receives 
lymphatics  from  the  anterior  part  of  the  caecum 
and  base  of  the  appendix  by  vessels  which  pass 
through  the  anterior  colic  fold.  Vessels  from  the 
posterior  aspect  of  the  caecum  also  join  the  ^ileo- 
colic  group.  These  vessels  do  not  communicate 
with  the  lymphatics  of  the  iliac  or  lumbar  regions 
(Jamieson  and  Dobson).  The  vessels  which  issue 
from  the  ileo-colic  group  of  glands  join  the  efferent 
vessels  of  the  small  intestine  and  of  the  ascending 
colon,  and  enter  glands  situated  along  the  superior 
mesenteric  artery. 

It  is  in  the  ileo-caecal  region  that  intussuscep= 
tion  most  frequently  occurs.  In  this  condition 
one  part  of  the  intestine  is  prolapsed  or  "  tele- 
scoped "  into  the  lumen  of  an  immediately  adjoin- 
ing part.  In  the  ileo-caecal  variety  (the  commonest 
form)  the  narrow  ileum,  and  subsequently  the 
caecum,  are  prolapsed  into  the  colon.  The  ileo- 
csecal  orifice  forms  the  summit  of  the  protrusion 
or  intussusceptum.  In  the  ileo-colic  variety  (the 
rare  form)  the  end  of  the  ileum  is  prolapsed 
through  the  valve.  The  orifice  and  the  caecum 
remain  in  their  normal  situations,  and  the  sum- 
mit of  the  intussusceptum  is  formed  only  by  the 
ileum.  In  another  variety,  which  is  also  common, 
the  apex  of  the^  intussusceptum  is  formed  by  the 
fundus  of  the  invaginated  caecum. 

There  are  three  fairly  constant  peritoneal 
fossae,  which  are  sometimes  the  seat  of  hernia,  in 
the  ileo-csecal  region  (Fig.  92).  They  are:  (1)  the 


422  ABDOMEN  AND  PELVIS  [CHAP. 

ileo-colic,  situated  between  the  ascending  colon 
and  termination  of  the  ileum — a  fold  containing 
the  anterior  csecal  artery  bounds  it  above;  (2)  the 
ileo-caecal  fossa,  between  the  termination  of  the 
ileum  and  the  caecum — it  is  bounded  in  front  by 
the  bloodless  (ileo-csecal)  fold  and  behind  by  the 
mesentery  of  the  appendix;  (3)  the  retrocaecal 
fossa,  behind  the  caecum — it  is  bounded  on  the 
right  by  the  lower  termination  of  the  ascending 
mesocolon. 

Rate  at  wliic'li  tli<*  content  *  of  ih<- 
alimentary  canal  progress.— A  study  of  the 
movements  of  a  bismuth-laden  diet  along  the 
alimentary  canal  of  the  living  materially  modifies 
the  conception  one  forms  of  the  bowel  from  an 
examination  of  this  part  in  the  dead.  The  account 
given  here  is  founded  chiefly  on  the  observations 
of  Dr.  A.  F.  Hurst.  The  contents  of  the  stomach 
begin  to  pass  into  the  duodenum  very  soon  after 
food  is  taken ;  in  4|  hours  the  food  begins  to 
enter  the  caecum,  which  gradually  fills.  In  6| 
hours  the^  bismuth-laden  contents  have  reached 
the  hepatic  flexure,  and  in  9  hours  the  splenic 
flexure.  In  the  ascending  colon  and  first  part  of 
the  transverse  colon  the  fluid  part  of  the  fasces 
is  absorbed.  The  progress  along  the  descending 
iliac  and  pelvic  colon  is  slow.  In  30  hours  the 
bismuth  diet  is  lodged  in  the  iliac  and  pelvic 
colons.  The  colon  must  be  regarded  not  as  a 
passive  tube,  but  as  an  active  muscular  organ 
concerned  in  propulsion  as  well  as  absorption. 

Large  intestine.— From  the  caecum  to  the 
pelvi-rectal  junction  this  portion  of  the  bowel  is 
accessible  to  pressure  except  at  the  hepatic  and 
splenic  flexures,  which  are  deeply  placed.  The 
hepatic  flexure  is  under  the  shadow  of  the  liver, 
and  the  splenic  curve,  which  reaches  a  higher 
level,  is  behind  the  stomach  (Fig.  85,  p.  392).  The 
transverse  colon  crosses  the  belly  transversely,  so 
that  its  lower  border  is  nearly  on  a  level  with 
the  umbilicus  (Fig.  85).  In  cases  of  faecal  ac- 
cumulation the  outline  of  the  colon,  with  the 


xvni]  THE   LARGE  INTESTINE  423 

exception  of  the  two  flexures  above  named,  may 
be  distinctly  denned.  In  distensions  of  the  small 
intestine  the  belly  tends  to  present  the  greatest 
degree  of  swelling  in  front,  and  about  and  below 
the  navel.  In  distension  of  the  larger  gut  the 
front  of  the  abdomen  may  remain  (for  a  while  at 
least)  comparatively  flat,  while  the  distension  will 
be  most  obvious  in  the  two  flanks  and  in  the 
region  just  above  the  umbilicus.  Tumours  of  the 
transverse  colon,  and  of  the  lower  two-thirds  of 
the  ascending  and  descending  colon,  can  be  well 
defined,  even  when  of  moderate  size,  and  in  cases 
of  intussusception  the  progress  of  the  mass  along 
the  colon  can  often  be  traced  with  great  ease,  and 
the  effects  of  enemata  and  other  methods  of  re- 
duction carefully  watched.  The  diameter  of  the 
large  intestine  (excluding  the  rectum)  gradually 
diminishes  from  the  caecum  to  the  iliac  colon, 
that  of  the  former  being  about  2^  inches,  and 
of  the  latter  1^  inches.  The  narrowest  part  of  this 
segment  of  the  bowel  is  at  the  point  of  junction 
of  the  pelvic  colon  with  the  rectum,  and  it  is 
significant  that  this  is  the  point  at  which  stric- 
ture is  the  most  common.  At  this  point,  too,  is 
situated  the  pelvic  rectal  sphincteric  tract. 

The  tendency  to  stricture  increases  as  one 
proceeds  from  the  caecum  to  the  anus.  A  stric- 
ture is  frequent  in  the  descending  colon,  less 
frequent  in  the  transverse  colon,  while  in  the 
ascending  colon  it  is  comparatively  rare.  Stric- 
tures are  not  uncommon  about  the  flexures  of  the 
bowels.* 

The  ascending  and  the  descending  colon  are 
placed  vertically.  The  average  length  of  the  as- 
cending colon  in  the  adult  (as  measured  from  the 
tip  of  the  caecum  to  the  hepatic  flexure)  is  8  inches. 
The  average  length  of  the  descending  colon, 
measured  from  the  sDlenic  flexure  to  the  iliac 
crest,  is  rather  less.  The  descending  colon  is  very 
little  liable  to  variation,  and  is  always  found  in  a 
semi-contracted  condition.  That  part  of  the  colon 

*  See  "Intestinal  Obstruction,"  by  Sir  Frederick  Treves.   London,  1S99. 


424  ABDOMEN  AND  PELVIS  [CHAP. 

which  lies  in  the  left  iliac  fossa,  from  the  iliac 
crest  to  the  left  psoas  muscle,  is  distinguished  as 
the  iliac  colon.  In  cases  of  non-descent  of  the 
caecum  the  ascending  colon  may  be  apparently 
absent.  Sir  Frederick  Treves  has  pointed  out 
that  in  52  per  cent,  of  adult  bodies  there  is 
neither  an  ascending  nor  a  descending  meso- 
colon,  and  that  a  mesocolon  may  be  expected 
on  the  left  side  in  36  per  cent,  of  all  cases,  and 
on  the  right  side  in  26  per  cent.  These  points 
are  of  importance  in  connexion  with  the  some- 
what uncommon  operation  of  lumbar  colotomy. 
The  breadth  of  the  mesocolon,  when  it  exists, 
varies  from  1  to  3  inches.  The  line  of  attach- 
ment of  the  left  mesocolon  is  usually  along  the 
outer  border  of  the  kidney,  and  is  vertical.  That 
of  the  right  mesocolon  is,  as  a  rule,  less  vertical, 
runs  along  the  outer  border  of  the  kidney,  and 
crosses  its  lower  end  obliquely  from  right  to  left. 
The  transverse  colon  has  an  average  measure- 
ment of  20  inches.  It  is  not  quite  horizontal, 
since  the  splenic  flexure  is  on  a  higher  level  than 
the  hepatic  flexure,  as  well  as  posterior  to  it,  and 
always  shows  a  number  of  bends,  one  occurring 
near  its  commencement  and  another  near  its  end 
(Fig.  85,  p.  392).  Faecal  masses  lodged  in  the 
transverse  colon  have  given  rise  to  many  errors 
in  diagnosis.  In  some  instances  this  part  of  the 
colon  is  displaced  towards  the  pelvis,  so  that 
V-  or  U-shaped  bends  are  produced.  In  such 
cases  the  point  of  the  V  or  the  U  may  reach  the 
symphysis  pubis,  while  the  two  colic  flexures 
occupy  their  proper  situations.  The  sagging  and 
elongation  of  the  transverse  colon  indicate  a  loss 
of  tone  and  of  contraction  in  its  muscular  coat, 
especially  of  the  longitudinal  tsenise.  There  is 
a  corresponding  relaxation  in  the  muscular  walls 
of  the  abdomen,  so  that  the  normal  support  is 
withdrawn  from  the  abdominal  viscera.  The 
peritoneal  supports  of  the  hepatic  and  splenic 
flexure  become  stretched  and  appear  to  compress 
and  obstruct  the  free  passage  of  the  colic  contents. 


xvm]  PELVIC  COLON  425 

The  constipation  in  such  cases  appears  to  be  due, 
not  to  the  kinking  and  compression  of  the  colon, 
but  to  the  primary  relaxation  of  the  colic  mus- 
culature, the  cause  of  which  is  still  obscure. 

The  right-hand  part  of  the  transverse  colon 
is  in  intimate  relation  with  the  gall-bladder,  and 
is  commonly  found  to  be  bile-stained  after  death. 
In  some  cases  where  gall-stones  have  been  lodged 
within  the  gall-bladder,  the  walls  of  that  struc- 
ture have  ulcerated  from  pressure,  the  ulceration 
has  involved  the  subjacent  transverse  colon,  and 
thus  a  fistula  has  been  established  between  the 
gall-bladder  and  the  gut,  through  which  large 
stones  have  been  passed.  Hepatic  abscesses  also 
have  discharged  themselves  through  the  trans- 
verse colon.  The  transverse  colon  often  finds  its 
way  into  an  umbilical  hernia,  and  is  concerned 
in  many  of  the  cases  of  hernia  into  the  foramen 
of  Winslow  (epiploicum). 

The  pelvic  colon  commences  as  the  colon  crosses 
the  left  psoas,  and  ends  in  the  pelvis,  usually 
opposite  the  third  piece  of  the  sacrum.  Its  ter- 
mination is  marked  by  three  features:  (1)  There 
is  a  contraction  in  the  diameter — the  pelvi-rectal 
sphincteric  tract;  (2)  the  peritoneum  ceases  to 
enclose  the  colon  completely  and  form  a  true 
mesentery;  (3)  the  three  longitudinal  tsenise  be- 
come spread  out  to  form  a  continuous  longitudinal 
muscular  coat.  Sir  Frederick  Treves  was  the  first 
to  distinguish  the  pelvic  colon  as  a  separate  seg- 
ment of  the  colic  tract,  applying  to  it  the  term 
"omega  loop,"  because  it  resembles  the  capital 
omega,  ft.  Although  termed  "  pelvic  colon,"  it 
should  be  remembered  that  in  the  foetus  and  in 
the  child  it  is  not  pelvic  but  suprapelvic  in 
position.  Frequently  it  is  spoken  of  as  the  "sig- 
moid  loop."  The  average  length  of  the  loop  in 
the  adult  is  17|  inches.  The  two  extremities  of 
the  loop  are  about  3  or  4  inches  apart.  If  they  are 
approximated  to  one  another,  as  by  contracting 
peritonitis  at  the  root  of  the  sigmoid  mesocolon,  a 
kind  of  pedicle  is  established,  about  which  the 
o* 


426 


ABDOMEN  AND  PELVIS 


[CHAP. 


loop  may  readily  become  twisted.  Such  a  twist, 
of  the  bowel  constitutes  a  volvulus  of  the  pelvic 
colon  or  loop ;  and  it  may  be  here  said  that  vol- 
vulus of  the  intestine  is  more  commonly  met  with 
in  this  loop  than  in  any  other  part  of  the  canal. 

The  line  of  attachment  of  the  mesentery  of  the 
pelvic  colon  crosses  the  left  psoas  muscle  and  the 


cc.e 


Fig.   94. — Sigmoid   flexure  (pelvic  colon)  turned   upwards 

to  show  the  intersigmoid  fossa.     (Jonnesco.) 
S.F,  Sigmoid  flexure  ;  a.s,  sigmoid  artery  ;  M  c,  intersigmoid  fossa  ; 
a.e,  external  iliac  artery  ;  U,  ureter  in  front  of  internal  iliac 


iliac  vessels  near  their  bifurcation;  it  then  turns 
abruptly  down,  and,  running  nearly  vertical,  ter- 
minates at  the  middle  line.  In  the  left  wall  of 
this  mesocolon.  close  to  the  point  where  it  lies  over 
the  iliac  vessels,  a  fossa  is  sometimes  to  be  found 
(Fig.  94,  MC)  ;  it  is  produced  by  the  sigmoid  artery, 


xvm]  PELVIC  COLON  427 

and  is  about  l£  inches  in  depth.  It  is  called  the 
intersigmoid  fossa,  and  is  the  seat  of  sigmoid 
hernia.  Cases  of  strangulated  hernia  in  this 
fossa  have  been  recorded. 

The  pelvic  colon,  when  empty,  normally  occu- 
pies the  pelvis.  When  distended  this  piece  of 
bowel  may  become  so  enormously  dilated  as  to 
reach  the  liver.  The  chief  examples  of  extra- 
ordinary dilatation  of  the  colon  concern  this  loop, 
as  in  megacolon  or  Hirschsprung' s  disease,  where 
there  is  apparently  an  extraordinary  degree  of 
dilatation  and  hypertrophy  of  the  muscular  coat, 
and  yet  such  coats  have  no  power  of  contraction. 
Fsecal  masses  are  very  frequently  lodged  in  the 
distal  part  of  the  pelvic  colon,  and  certain  in- 
testinal concretions  have  been  met  with  in  the 
same  situation. 

Sir  Frederick  Treves  demonstrated  by  experi- 
ment that  the  "  long  tube,"  when  introduced 
through  the  anus,  could  not  be  passed  beyond  the 
sigmoid  flexure  in  ordinary  cases  and  with  a 
normal  disposition  of  the  bowel. 

In  cases  of  congenital  absence  or  deficiency 
of  the  rectum,  the  pelvic  colon — in  some  cases  the 
iliac  colon — is  opened  in  the  groin  and  an 
artificial  anus  established  there.  One  difficulty  has 
been  said  to  depend  upon  the  uncertain  position 
of  the  pelvic  colon  in  cases  of  congenital  de- 
formity, it  being  sometimes  on  the  right  side 
and  sometimes  in  the  pelvis  at  the  middle  line. 
It  is  rarely,  however,  found  in  these  positions. 
Out  of  100  post-mortem  examinations  on  young 
infants,  Curling  found  the  loop  on  the  left  side 
in  85  cases.  Out  of  10  children  who  were  operated 
on  for  imperforate  anus,  the  loop  was  found  in 
the  left  fossa  in  only  1  case  (Montgomery). 

The  iliac  and  pelvic  colons  are  often  the 
seat  of  multiple  diverticula  of  the  mucous  coat. 
These  diverticula  occur  at  points  where^  vessels 
enter  or  emerge  from  the  bowel,  thus  giving  rise 
to  ^weak  points  in  the  muscular  coat  through 
which  the  mucous  coat  forms  small  hernise  or 


428  ABDOMEN  AND  PELVIS  [CHAP. 

diverticula.  _  They  protrude  within  the  appen- 
dices epiploicse  and  root  of  the  mesentery.  This 
part  of  the  colon  serves  as  a  receptaculum  for 
the  faeces,  and  is  always  tonically  contracted, 
and  this  is  probably  the  reason  why  the  pelvic 
colon  is  more  frequently  the  seat  of  these  diver- 
ticula than  any  other  part  of  the  bowel. 

The  section  of  the  body  shown  in  Fig.  95  gives 
the  immediate  relations  of  the  descending  colon, 
and  the  structures  to  be  cut  through  if  the  sur- 
geon wishes  to  expose  this  structure  in  the  loins. 
The  position  of  the  descending  colon  in  the  loin 
may  be  represented^  by  a  line  drawn  vertically 
upwards  from  a  point  on  the  iliac  crest  1  inch 
external  to  the  outer  border  of  the  erector  spinse. 
An  incision  is  made  across  the  centre  of  this  line 
parallel  to  the  last  rib,  and  so  planned  that  the 
centre  of  the  incision  corresponds  to  the  centre  of 
the  line.  The  superficial  tissues  having  been  in- 
cised, the  following  structures  are  divided  in 
layers  in  the  order  here  given  (Fig.  95)  :  (1)  The 
latissimus  dorsi  and  external  oblique  muscles  to 
an  equal  extent;  (2)  the  internal  oblique  in  the 
entire  length  of  the  incision;  (3)  the  lumbar 
(lumbo-dorsal)  fascia,  with  a  few  of  the  most  pos- 
terior fibres  of  the  transversalis  muscle;  (4)  the 
transversalis  fascia.  The  quadratus  lumborum 
will  be  exposed  in  the  posterior  inch  or  so  of  the 
incision,  and  usually  does  not  need  to  be  cut.  At 
the  seat  of  the  operation  the  descending  colon 
occupies  the  angle  between  the  psoas  and  quad- 
ratus lumborum  muscles,  and  the  non-peritoneal 
surface  is  exactly  represented  by  that  part  of  the 
bowel  that  faces  this  angle  (Fig.  95).  Thus,  if 
during  the  operation  the  curved  finger  be  placed 
in  this  angle",  and  the  patient  be  rolled  over  to 
the  left  side,  the  bowel  that  falls  into  the  finger 
cannot^  well  be  other  than  the  descending  colon. 
The  width  of  the  non-peritoneal  surface  varies 
from  f  of  an  inch  to  1  inch  in  the  empty  state, 
and  may  attain  to  2  inches  or  more  in  the  dis- 
tended condition  (Braune). 


XVIIl] 


COLOTOMY 


429 


Iliac  or  inguinal  colotomy.  —  In  this  very 
common,  excellent,  and  simple  operation  the  pel- 
vic colon  is  exposed  and  opened  in  the  left 
iliac  region.  A  line  is  drawn  from  the  anterior 
superior  iliac  spine  to  the  umbilicus,  and  an  in- 


TRANSVEftSE    COLON 


INF:  VENA  CAVA 
AOffTA 


EXTERNAL  OBLIQUE. 
INTERNAL  OBLIQ 
IS 


DESCENDING  COLON 


\      PSOAS 
QUADRATUS  LUMBORUM 


Fig.  95. —Horizontal  section  through  the  body  at  the  level 
of  the  umbilicus.     (After  Braune.} 

cision  some  2  inches  in  length  is  made  at  right 
angles  to  this  line  and  at  a  distance  of  about 
1|  inches  from  the  point  of  the  bone?  The  three 
muscles  of  the  abdomen  and  the  peritoneum  hav- 
ing been  divided,  the  loop  of  the  pelvic  flexure 
is  brought  into  the  wound,  is  secured,  and  is  (at 


430  ABDOMEN  AND  PELVIS  [CHAP. 

once  or  at  a  later  period)  opened.  The  ascending 
branch  of  the  deep  circumflex  iliac  artery  crosses 
the  line  of  the  incision.  The  iliac  colon  is  bound 
by  a  very  short  mesentery  to  the  iliac  fossa,  but, 
owing  to  the  mobility  of  the  peritoneum  in  this 
region,  the  bowel  is  easily  brought  into  the 
wound. 

The  caecum  may  be  opened  on  the  right  side, 
and  as  a  rule  the  most  convenient  incision  is  an 
oblique  one  placed  externally  to  the  deep  epigastric 
artery.  The  appendix  has  also  been  opened  and 
sutured  to  the  incision  in  the  groin  (appendi- 
costomy).  Through  the  opening  in  the  appendix 
the  caecum  and  colon  may  be  irrigated  and 
washed  out. 

Colectomy  consists  in  excising  a  portion,  or  the 
whole,  of  the  colon.  The  caecum  has  been  removed, 
and  considerable  segments  of  the  rest  of  the  large 
intestine.  The  treatment  of  cancer  ^  of  the  colon 
by  excision  is  attended  with  considerable  suc- 
cess. Portions  of  the  ascending  and  descending 
parts  of  the  colon  have  been  excised  through  an 
incision  in  the  loin,  but  colectomy  is  much  more 
readily  carried  out  througn  an  anterior  wound. 
In  the  case  of  a  young  girl,  Sir  Frederick  Treyes 
excised  the  whole  rectum  and  anus,  the  sig- 
moid  flexure,  and  the  whole  of  the  descending 
colon.  The  divided  transverse  colon  was  brought 
out  at  the  anus.  The  child  made  a  perfect  re- 
covery. The  parts  removed  are  in  the  museum  of 
the  Royal  College  of  Surgeons.  The  operation 
of  intestinal  anastomosis  or  short-circuiting  is 
very  frequently  practised  on  the  colon.  Thus,  in 
an  obstruction  of  the  descending  colon  impossible 
of  removal,  the  transverse  colon  may  be  united 
to  the  sigmoid  flexure. 

In  more  recent  years  Sir  W.  Arbuthnot  Lane 
has  applied  excision  of  the  great  bowel  to  cases 
of  obstinate  constipation  and  toxaemia  which  are 
unrelieved  by  all  known  medical  measures,  especi- 
ally to  those  cases  where  the  transverse  colon  is 
greatly  elongated  and  kinked  (see  p.  424).  In 


xvin]          MALFORMATIONS   OF  COLON  431 

many  cases  the  operation  is  attended  with  marked 
success.  In  cases  of  obstinate  colitis  the  great 
bowel  may  be  "  rested  "  by  uniting  the  lower 
pa-rt  of  the  ileum  to  the  pelvic  colon,  thus 
short-circuiting  the  food  passage.  The  results  of 
such  operations  are  often  favourable,  and  have- 
been  cited  in  support  of  the  theory,  promulgated 
by  Metchnikoff,  that  the  great  bowel  is  a  useless 
and  dangerous  structure  in  man.  The  evidence, 
so  far  as  it  goes,  indicates  that  no  colon  is 
better  than  a  diseased  colon,  but  it  certainly 
does  not  signify  that  no  colon  is  better  than  a 
healthy  one.  In  cases  of  ileo-sigmoid  anastomosis 
the  iliac  contents  are  often  carried  backwards  into 
the  colon  by  a  process  of  antiperistalsis,  leading 
even  to  a  loading  of  the  colon. 

Congenital  malformations  of  the  colon. — 
These  are  of  moment  with  regard  to  operative 
procedures.  It  may  be  very  briefly  said  that  in 
the  foetus  the  small  bowel  occupies  at  one  time 
the  right  side  of  the  abdomen,  while  the  large  gut 
is  represented  by  a  straight  tube  that  passes  on 
the  left  side  vertically  from  the  region  of  the 
umbilicus  to  the  pelvis.  The  caecum  is  at  first 
situated  within  the  umbilicus,  and  then  ascends  in 
the  abdomen  towards  the  left  hypochondrium.  It 
next  passes  transversely  to  the  right  hypochon- 
drium, and  then  descends  into  the  corresponding 
iliac  fossa.  It  may  be  permanently  arrested  at 
any  part  of  its  course.  Thus  the  caecum  may  be 
found  about  the  umbilicus,  or  in  a  congenital 
umbilical  hernia,  or  in  the  left  hypochondriac 
region  (the  ascending  and  transverse  parts  of  the 
C9lon  being  absent),  or  it  may  be  found  in  the 
right  hypochondrium,  the  ascending  colon  only 
being  unrepresented. 

^Tlic  whole  of  the  large  intestine  has  at  0110 
time  an  extensive  mesentery,  and  in  some  rare 
cases  this  condition  may  persist  throughout  life. 
When  it  does  persist,  it  may  lead  to  one  form  of 
volvulus  of  the  bowel. 


CHAPTER   XIX 
THE    OTHER   ABDOMINAL   VISCERA 

The  liver.  —  The  liver  is  moulded  to  the  arch 
of  the  diaphragm,  and  lies  over  a  part  of  the 
stomach  (Fig.  96).  Properly  speaking,  it  has  only 
two  surfaces — a  visceral  surface,  which  in  the 
upright  posture  rests  on  the  stomach,  duodenum, 
gastro-hepatic  omentum,  neck  of  the  pancreas, 
hepatic  flexure  of  colon,  right  kidney,  and  right 
suprarenal  body;  and  a  parietal  surface,  in  con- 
tact with  the  diaphragm  and  anterior  belly-wall 
in  the  subcostal  angle.  As  seen  from  the  front  it 
is  triangular  in  outline,  with  its  apex  near  the 
apex  of  the  heart  (Fig.  96);  its  upper  border  is 
best  indicated  by  a  line  commencing  at  the  apex 
beat  (Fig.  96)  and  passing  across  the  mid-line 
\  an  inch  below  the  sterno-ensiform  point;  it 
ascends  as  it  reaches  the  nipple  line  to  the  level  of 
the  sterno-ensiform  plane.  The  lower  border  com- 
mences at  the  apex  beat,  crosses  the  mid-line  about 
1  inch  above  the  mid-epigastric  point,  reaches 
the  costal  margin  at  the  outer  border  of  the 
rectus,  and  the  remainder  of  its  lower  border 
corresponds  to  the  costal  margin  as  far  as  the  tip 
of  the  eleventh  rib..  The  liver  is  in  contact  with 
the  right  kidney  along  the  lower  margin  of  that 
rib  (Fig.  97).  For  surgical  purposes  the  liver  in 
the  right  hypochondrium  may  be  regarded  as 
made  up  of  three  zones — an  upper  or  pulmonary, 
a  middle  or  pleural,  and  a  lower  or  diaphrag- 
matic (Figs.  96,  97).  In  the  lower  zone,  which  is 
1|  to  2  inches  wide  in  the  mid-axillary  line,  the 
liver  may  be  incised  or  explored;  in  the  middle 
zone,  which  is  of  equal  width,  the  pleural  reflec- 
432 


THE    LIVER 


433 


tion  is  encountered.  In  the  erect  posture  the  lower 
edge  on  the  right  side  is  about  \  or  J  of  an  inch 
below  the  margins  of  the  costal  cartilages.  In  the 
recumbent  position  the  liver  ascends  about  an 
inch,  and  is  entirely  covered  by  the  costse,  except 
at  the  subcostal  angle.  It  ascends  also  in  ex- 
piration and  descends  in  inspiration. 

The  fundus  of  the  gall-bladder  approaches  the 
surface  behind  the  ninth  costal  cartilage,  close  to 


-^-J^l  Pi  PUPAL  Ll/IE 
K     V        JflEPATlC  DUCT 

^\    ^-<!  CYSTIC  DUCT 
PANCREAS 


POI/IT 


LIAIE, 


AIio  EPIQASTRIC  LI/IE 

PyLOEUS 
5TOA1ACH 

LE  DUCT 


LI/MEA  ALBA 
UMBILICAL  line. 

1  LI/1EA  5EAHLU/1ARI5 


Fig.  96. — Showing  the  position  of  the  liver,  gall-bladder, 
bile-ducts,  and  pancreas. 

The  lower  limits  of  the  pleura  and  lung  are  indicated. 

the  outer  border  of  the  right  rectus  muscle  (Fig. 
96).  Its  position  is  extremely  variable;  it  fre- 
quently occupies  a  position  considerably  below 
and  external  to  the  one  mentioned. 

The  liver  is  retained  in  shape  by,  and  moulded 
upon,  the  diaphragm  above  and  the  abdominal 
organs  below.  When  removed  from  the  body  the 
shape  which  it  possesses  clinically  is  lost.  It 


434  ABDOMEN  AND  PELVIS  [CHAP. 

presents  many  variations  in  form.  One  of  the  com- 
monest is  a  linguiform  process  (often  referred  to 
as  RiedePs  lobe),  which  projects  from  the  margin 
of  the  right  lobe  under  the  tenth  costal  cartilage 
(Fig.  86,  p.  393).  It  is  found  more  frequently  in 
women  than  in  men,  and  may  be  mistaken  for  a 
floating  kidney  or  an  abdominal  tumour. 

In  the  condition  known  as  ptosis  of  the  liver 
the  upper  surface  slides  forwards  in  the  dome  of 
the  diaphragm,  and  its  lower  border  may  descend 
to  the  level  of  the  umbilicus  or  reach  the  iliac 
fossa  (Fig.  86).  With  the  descent  there  is  also 
a  rotation  on  its  transverse  axis,  so  that  its 
diaphragmatic  surface  comes  almost  completely 
to  the  front.  In  such  a  case  the  factors  which 
maintain  the  liver  in  position  have  to  be 
considered.  They  are:  (1)  Its  fixation  to  the 
diaphragm  by  the  inferior  vena  cava  and  the 
fibrous  tissue  on  the  non-peritoneal  posterior 
(dorsal)  surface  of  the  right  lobe  in  the  neigh- 
bourhood of  the  inferior  vena  cava;  it  is  con- 
venient to  distinguish  this  attachment  as  the 
mesohepar.  (2)  The  peritoneal  folds,  which  include 
the  right  and  left  lateral  (triangular),  coronary, 
and  falciform  ligaments,  also  attach  it  to  the 
diaphragm.  These  folds  are  lax,  in  order  to  allow 
the  free  movements  of  the  liver  which  occur  during 
respiration  and  in  the  filling  and  emptying  of 
the  stomach.  (3)  The  muscular  abdominal  walls, 
which  keep  the  other  abdominal  viscera  constantly 
pressed  against  the  lower  surface  of  the  liver. 
The  muscles  constitute  the  chief  means  of  main- 
taining the  liver  in  position.  In  many  women 
over  40  the  right  lobe  of  the  liver  projects  quite 
2  inches  below  the  eleventh  rib,  and,  as  in  the 
child,  the  extremity  of  the  left  lobe  frequently 
comes  in  contact  with,  or  even  overlaps,  the  upper 
part  of  the  spleen. 

The  liver  is  more  often  ruptured  from  con- 
tusion than  is  any  other  abdominal  viscus.  This 
is  explained  by  its  large  size,  its  comparatively 
fixed  position,  its  great  friability  of  structure, 


xix]  WOUNDS   OF  THE   LIVER  435 

and  the  large  quantity  of  blood  contained  in  its 
vessels.  A  normal  liver  will  take  its  own  weight 
of  blood  if  its  veins  be  injected  at  ventricu- 
lar pressure  (Salaman).  Death  in  such  injuries 
usually  ensues  from  haemorrhage,  since  the  walls 
of  the  portal  and  hepatic  veins,  being  incorpo- 
rated with  the  liver  substance,  are  unable  to  re- 
tract or  to  collapse.  The  hepatic  veins  also  open 
direct  into  the  vena  cava,  and,  being  unprovided 
with  valves,  could  allow  of  the  escape  of  an 
immense  quantity  of  blood  if  any  retrograde 
current  were  established.  The  hepatic  vessels 
are  thin-walled,  and  it  is  almost  impossible  to 
ligature  them,  except  by  buried  sutures.  It  is 
possible  for  the  liver  to  be  ruptured  without  the 
peritoneal  coat  being  damaged;  and  such  injuries 
may  be  readily  recovered  from.  The  liver  pre- 
sents, behind,  a  fairly  extensive  non-peritoneal 
surface,  at  which  rupture  or  wound  may  occur 
without  extravasation  into  the  abdominal  cavity. 
From  the  relation  of  the  liver  to  the  right  lower 
ribs,  it  follows  that  this  viscus  may  be  damaged 
when  the  ribs  are  fractured,  and  in  some  cases 
the  broken  ends  of  the  bones  have  been  driven 
through  the  diaphragm  into  the  liver  substance. 
Stabs!  through  the  sixth  or  seventh  right  inter- 
costal space,  over  the  liver  region,  would  wound 
both  the  lung  and  the  liver,  would  involve  the 
diaphragm,  and  open  up  both  the  pleural  and 
peritoneal  cavities. 

The  intimate  relation  of  the  liver  to  the 
transverse  colon  is  illustrated  by  a  case  where 
a  toothpick,  4  inches  in  length,  was  found  in 
the  substance  of  the  liver.  It  had  worked 
its  way  there,  from  the  colon,  along  an  abscess 
cavity  which  connected  the  two  viscera.  The 
relation  of  the  liver  to  the  heart  may  be  illus- 
trated by  a  case  still  more  remarkable.  In  this 
instance  a  loose  piece  of  liver,  weighing  one 
drachm,  was  found  in  the  pulmonary  artery.  The 
patient  had  been  crushed  between  two  wagons, 
the  liver  was  ruptured  and  the  diaphragm  torn, 


436  ABDOMEN  AND  PELVIS  [CHAP. 

a  common  result  of  crushing  accidents  and  a 
prolific  source  of  diaphragmatic  hernia.  A  piece 
of  the  liver  had  been  squeezed  along  the  vena  cava 
into  the  right  auricle,  whence  it  had  passed  into 
the  right  ventricle,  and  so  into  the  pulmonary 
artery.  The  heart  itself  was  quite  uninjured. 
Bullets  lodging  in  the  liver  may  ultimately  bo 
carried  to  the  cavity  of  the  right  ventricle.  Con- 
siderable portions  of  the  liver  have  been  removed 
with  success.  It  is  remarkable  from  what  grave 
injuries  of  the  liver  recovery  is  possible.  Thus,  Dr. 
Gann  (Lancet,  June,  1894)  reports  the  case  of  a 
man  of  28  who  had  a  harpoon  driven  through  the 
whole  thickness  of  the  right  lobe  of  the  liver,  so 
that  it  projected  at  the  posterior  border.  The 
blade  was  7  inches  long,  and  had  two  barbs.  It 
was  removed  by  operation  twenty-eight  hours 
after  the  accident,  and  the  patient  made  a  good 
recovery. 

From  a  reference  to  the  relations  of  the  liver  it 
will  be  readily  understood  that  an  hepatic  abscess 
may  open  into  the  pleura,  and  in  some  cases, 
indeed,  the  pus  from  the  liver  has  been  discharged 
from  the  trachea.  Thus,  it  has  been  possible  for  a 
patient  to  cough  up  some  portion  of  his  liver, 
although,  of  course,  in  a  very  disintegrated  and 
minute  form.  Hepatic  abscess  may  burst  in  one 
or  other  of  the  following  directions,  placed  in 
order  of  their  frequency  :  (1)  into  the  right  lung; 
(2)  into  the  bowel;  (3)  upon  the  surface  of  the 
body.  Such  abscesses  have,  in  rare  cases,  opened 
into  the  stomach.  The  liver  is  very  frequently 
the  seat  of  the  secondary  abscess  of  pyaemia,  and, 
according  to  Mr.  Bryant's  statistics,  abscesses  in 
this  viscus  are  more  common  after  injuries  to  the 
head  than  after  injuries  elsewhere.  They  are 
rare  in  pyaemia  following  affections  of  the  urinary 
organs,  and  are  equally  rare*  in  the  pyaemia  after 
burns.  Secondary  deposits  of  tumours  and  ab- 
scesses are  frequently  limited  to  the  right  or  to 
the  left  of  a  line  drawn  from  the  fundus  of  the 
gall-bladder  to  the  inferior  vona  cava.  This  re- 


xix]  THE   GALL-BLADDER  437 

markable  limitation  is  to  be  explained  by  the  fact 
that  the  liver  to  the  right  of  this  line  is  supplied 
only  by  the  right  terminal  division  of  the  portal 
vein,  while  the  part  to  the  left  receives  blood  only 
from  the  left  division  (Cantlie). 

The  gall-bladder  may  be  absent,  as  is  the 
case  in  some  animals,  or  reduced  to  a  cicatrix 
from  disease.  It  is  often  removed  by  operation, 
and  no  disturbance  in  the  biliary  function  is 
apparent  (Moynihan).  Its  mucous  membrane  has 
a  peculiar  reticulated,  honeycomb  appearance,  and 
is  made  up  of  columnar  epithelium,  which  secretes 
mucus  and  has  a  power  of  absorption.  When 
inflamed  the  cells  pour  out  a  morbid  amount  of 
secretion,  in  which  the  cholesterin  of  the  bile  may 
become  deposited  if  the  outflow  is  obstructed, 
and  may  form  the  nuclei  of  gall=stones.  These 
are  composed  mostly  of  cholesterin,  a  normal  con- 
stituent of  bile,  and  vary  in  size  from  a  hemp- 
seed  to  a  hen's  egg.  The  escape  of  gall-stones 
is  rendered  more  difficult  by  the  presence  of  a 
spiral  fold  of  mucous  membrane  in  the  neck  and 
duct  of  the  gall-bladder.  The  gall-bladder,  at  its 
neck,  forms  an  acute  angle  with  the  cystic  duct, 
the  spiral  fold  serving,  as  in  a  rubber  pipe,  to 
keep  the  passage  open.  In  the  erect  position  the 
long  axis  of  the  gall-bladder  is  directed  upwards 
and  backwards,  and  the  cystic  duct  downwards 
and  forwards  (Fig.  96).  The  cystic  duct  lies 
in  the  gastro-hepatic  omentum  (hepato-duodenal 
part),  where  it  joins  the  hepatic  to  form  the 
common  bile-duct.  It  is  accompanied  by  the  cystic 
artery.  The  cystic  veins  pass  directly  to  the  liver 
and  end  in  the  portal  capillary  system.  In  cases 
of  cystitis  the  part  of  the  liver  receiving  the  cystic 
veins  is  seen  to  be  contracted  or  atrophied. 

A  gall-stone  may  be  arrested  in,  and  require 
removal  from,  any  part  of  the  cystic  or  the  com- 
mon bile-duct.  The  common  bile-duct  is  3  inches 
long,  and  its  lumen  i  of  an  inch  wide,  but  by  the 
passage  of  gall-stones  it  may  become  three  times 
its  normal  diameter.  The  upper  half  of  the 


438  ABDOMEN  AND  PELVIS  [CITAP. 

common  bile-duct  lies  in  the  gastro-hepatic  omen- 
turn,  in  front  of  the  epiploic  foramen  (Winslow's), 
with  the  portal  vein  behind  it  and  to  the  right. 
The  hepatic  artery  lies  close  on  its  left,  and  its 
branch,  the  superior  pancreatico-duodenal,  crosses 
the  common  bile-duct  as  it  passes  to  its  second 
or  deeper  stage.  A  stone  arrested  in  the  lower 
half  of  the  duct  is  difficult  of  access.  The  duct 
lies  buried  between  the  head  of  the  pancreas  be- 
hind and  the  duodenum  in  front  and  to  the  outer 
side.  It  may  be  necessary  in  such  a  case  to  open 
the  duodenum  and  extract  the  stone  through  its 
posterior  and  inner  wall,  or  the  duodenum  and 
head  of  the  pancreas  may  be  turned  forwards  from 
the  inner  border  of  the  right  kidney,  thus  expos- 
ing the  lower  half  (post-duodenal  stage)  of  the 
common  bile-duct  in  the  groove  between  the  duo- 
denum and  pancreas.  The  terminal  half-inch  is 
embedded  in  the  wall  of  the  duodenum  and  ends 
in  the  ampulla  of  Vater.  At  its  termination, 
where  the  duct  is  narrowest,  it  is  surrounded  by 
a  sphincter  (supra-ampullary  sphincter)  which 
regulates  the  flow  of  bile.  The  lumen  of  the 
lower  half  of  the  duct  is  less  than  that  of  the  upper 
half.  Two  lymphatic  glands  lie  in  the  gastro- 
hepatic  omentum  by  the  side  of  the  bile-duct, 
and  have  been  mistaken  for  gall-stones  when 
calcined.  In  its  ampullary  part  there  are  sub- 
mucous  glands,  which  are  liable  to  infection  and 
inflammation. 

The  gall-bladder  receives  its  nerve  supply  from 
the  eighth  and  ninth  segments  of  the  cord  (Head), 
through  the  great  splanchnic  and  creliac  plexus. 
The  intense  colic  caused  by  gall-stones,  believed 
to  be  due  to  spasm  of  the  non-striated  muscular 
coat  of  the  bile-ducts,  is  reflected  along  the  ninth 
dorsal  nerve  to  the  anterior  abdominal  wall. 
Stimulation  of  the  sympathetic  nerves  causes  the 
muscle  of  the  cystic  duct  to  contract,  but  relaxes 
that  of  the  gall-bladder  (T.  R.  Elliot).  The  con- 
tractions of  the  musculature  of  the  biliary  system 
are  correlated  with  the  movements  of  the  stomach, 


xix]        OPERATIONS   ON   GALL-BLABBER        430 

and  hence  are  liable  to  occur  soon  after  taking 
food  (Lynn  Thomas). 

The  gall-bladder  and  the  bile-duct  have  been 
ruptured  alone  without  rupture  of  the  liver.  The 
injury  is  rapidly  fatal,  owing  to  the  escape  of  bile 
into  the  peritoneal  cavity.  Large  gall-stones  may 
be  passed  direct  into  the  bowel  through  a  fistulous 
track  which  has  been  established  between  the  gall- 
bladder and  the  intestine.  Gall-stones  have  sup- 
purated out  through  the  anterior  belly-wall,  and 
have  been  removed  from  abscesses  in  the  parietes. 
Thus,  Burney  Yeo  reported  a  case  where  more 
than  one  hundred  gall-stones  were  discharged 
though  a  spontaneous  fistula  in  the  hypogastric 
region,  5  inches  below  the  umbilicus.  In  cases 
where  the  bile-duct  is  occluded  by  gall-stones,  or 
by  other  causes,  the  gall-bladder  may  become 
enormously  distended,  and  may  form  a  tumour 
extending  some  way  beyond  the  umbilicus.  So 
large  .a  tumour  has  been  formed  that  the  mjass  has 
been  mistaken  for  an  ovarian  cyst.  The  gall- 
bladder as  it  enlarges  tends  to  follow  a  line 
extending  from  the  tip  of  the  right  tenth  car- 
tilage across  the  median  line  of  the  abdomen  below 
the  umbilicus.  For  the  relief  of  this  condition, 
cholecystotomy,  or  incision  into  the  gall-bladder, 
lias  been  performed.  In  this  operation  the  in- 
cision or  puncture  is  made  over  the  most  promi- 
nent part  of  the  tumour.  Impacted  gall-stones 
have  been  removed  entire  from  the  bile-duct 
through  an  incision  so  made,  or  the  stone  has  been 
crushed  in  situ  and  extracted  in  fragments. 

In  cholecystectomy  the  whole  of  the  gall-blad- 
der is  excised  and  the  cystic  duct  closed.  The  bile 
finds  its  way  into  the  intestine  direct  through  the 
common  duct. 

In  cholecystenterostomy  a  fistula  is  established 
between  the  gall-bladder  and  the  intestine.  The 
operation  is  carried  out  in  cases  in  which  there 
is  an  insuperable  obstruction  in  the  common 
duct.  The  gall-bladder  thus  takes  the  place  of 
the  common  duct. 


440 


ABDOMEN  AND  PELVIS 


[CHAP. 


The  spleen.— The  spleen  is  deeply  situated  in 
the  left  hypochondriac  region,  and  in  the  normal 
condition  cannot  be  palpated,  being  quite  covered 
in  front  by  the  cardiac  end  of  the  stomach  (Fig. 
98).  It  most  closely  approaches  the  surface  in 
the  parts  covered  by  the  tenth  and  eleventh  ribs. 
Above  this  it  is  entirely  overlapped  by  the  edge 


Fig.  97. — Position  and  relationships  of  the  abdominal 
viscera  from  behind. 

The  lower  limits  of  the  pleura  and  lung  are  shown  in  red. 

of  the  lung.  It  is  in  all  parts  separated  from 
the  parietes  by  the  diaphragm.  "  It  lies  very 
obliquely,  its  long  axis  coinciding  almost  exactly 
with  the  line  of  the  tenth  rib.  Its  highest  and 
lowest  points  are  on  a  level,  respectively,  with  the 
ninth  dorsal  and  first  lumbar  spines;  its  inner 
end  is  distant  about  Ij  inches  from  the  median 
plane  of  the  body,  and  its  outer  end  about  reaches 


xix]  THE   SPLEEN  441 

the  mid-axillary  line  "  (Quain)  (Fig.  97).  It  pos- 
sesses three  surfaces,  gastric,  renal,  and  phrenic, 
well  shown  in  Fig.  98. 

A  dislocated  or  floating  condition  of  the  spleen 
is  rare.  Its  hilus  is  attached  to  the  stomach  by 
the  gastro-splenic  fold  of  peritoneum.  Its  renal 
surface  is  closely  applied  to  the  upper  half  of  the 
left  kidney ;  its  gastric  surface  is  kept  in  apposition 
to  the  stomach;  its  upper  pole  is  attached  near 


Fig.  98. — Horizontal  section  through  upper  part  of 
abdomen.      (Rudingcr.) 

a,  Liver  ;  b,  stomach  ;  <:,  transverse  colon  ;  d,  spleen  ;  c,«,  kidneys  ; 
/,  pancreas  ;  g,  inferior  vena  ctiva ;  h,  aorta  with  thoracic  duct 
behind  it. 

the  cardiac  orifice  of  the  stomach  by  the  lieno- 
phrenic  fold  of  peritoneum,  while  its  lower  rests 
on  the  costo-colic  peritoneal  fold,  and  has  the  tail 
of  the  pancreas  and  colon  in  contact  with  it.  The 
tension  of  the  abdominal  walls  exerts  a  general 
pressure  on  it  through  the  other  abdominal 
organs.  When  the  spleen  enlarges,  as  in  ague,  its 
crenated  anterior  border  may  be  felt  beneath  the 
tenth  costal  cartilage.  The  movable  or  floating 


442  ABDOMEN  AND  PELVIS  [CHAP. 

spleen  is  met  with  only  in  adults.    The  organ  may 
be  so  displaced  as  to  reach  the  iliac  fossa. 

Injuries. — Although  extremely  friable  in  struc- 
ture, the  normal  spleen  is  not  very  frequently 
ruptured.  Its  connexions,  indeed,  tend  to  mini- 
mize the  effects  of  concussions  and  contusions. 
When  the  spleen,  however,  is  enlarged,  it  is  very 
readily  ruptured,  and  often  by  quite  insignifi- 
cant violence.  Thus,  several  cases  have  been  re- 
corded of  rupture  of  an  enlarged  spleen  by  mus- 
cular violence.  For  instance,  a  woman  ruptured 
her  spleen  in  an  attempt  to  save  herself  from  fall- 
ing, and  another  in  springing  aside  to  avoid  a 
blow.  The  patients  in  each  instance  were  natives 
of  India,  and  the  latter  case  gave  rise  to  a  charge 
of  homicide.  The  spleen  being  extremely  vas- 
cular, it  follows  that  ruptures  of  the  viscus  arc 
usually,  but  not  necessarily,  fatal  from  haemor- 
rhage. It  is  well  to  note,  in  connexion  with  this 
matter,  that  the  spleen  contains  most  blood  during 
digestion.  A  case  is  reported,  however,  of  a  boy 
who  met  with  an  accident  just  after  dinner,  and 
who  managed  to  walk  some  distance,  although 
his  spleen,  as  the  autopsy  revealed,  was  separ- 
ated into  three  portions.  He  lived  some  days. 
In  severe ^  fractures  of  the  ninth,  tenth,  and 
eleventh  ribs  the  spleen  may  be  damaged  and 
lacerated. 

The  capsule  of  the  spleen  contains  muscular 
tissue,  and  possesses  a  power  of  rhythmical  con- 
traction. This  fact  may  serve  to  explain  cases 
of  recovery  from  limited  wounds  of  the  organ, 
such  as  small  gunshot  wounds.  In  such  lesions 
the  capsule  may  contract  and  greatly  narrow  the 
hole  in  the  viscus,  while  the  track  of  the  bullet 
or  knife  may  become  filled  with  blood-clot,  and 
the  bleeding  thus  be  stayed. 

The  spleen  may  be  greatly  enlarged  ^in  certain 
diseased  conditions.  The  hypertrophied  spleen 
may  attain  such  dimensions  as  to  fill  nearly  tho 
whole  abdomen ;  in  one  case  a  cystic  tumour  so 
completely  occupied  both  iliac  fossae  that  it  was 


xix]  THE   PANCREAS      .  443 

mistaken  for  an  ovarian  cyst,  and  the  operation 
for   ovariotomy   was   commenced. 

Extirpation  of  the  spleen  has  been  successful 
in  cases  of  abdominal  wounds  with  protru- 
sion of  the  viscus.  It  has  also  been  performed 
with  fair  results  in  many  cases  of  hypertrophied 
spleen  and  of  wandering  spleen.  The  operation 
is  not  justifiable  in  cases  of  leukaemic  enlargement 
of  the  organ,  it  having  proved  invariably  fatal 
in  such  instances.  The  splenic  artery,  with  its 
large  accompanying  vein,  lies  in  the  lieno-renal 
ligament,  in  contact  with  the  tail  of  the  pancreas 
below. 

The  pancreas  lies  behind  the  stomach,  in 
front  of  the  first  and  second  lumbar  vertebrae 
(Fig.  96).  It  crosses  the  middle  line  behind  the 
mid-epigastric  line.  In  emaciated  subjects,  and 
when  the  stomach  and  colon  are  empty,  it  may 
sometimes  be  felt  on  deep  pressure,  especially 
in  those  who  are  the  subjects  of  visceroptosis ; 
prolapse  of  the  stomach  leaves  the  pancreas  ex- 
posed above  the  lesser  curvature.  It  is  in  relation 
with  many  most  important  structures.  So  closely 
is  it  mixed  up  with  the  solar  plexus  that  this 
structure  is  necessarily  involved  in  inflammatory 
conditions,  and  must  be  disturbed  in  any  operative 
procedures  on  its  head  and  neck.  The  pancreatic 
duct  (duct  of  Wirsung)  usually  ends  with  the 
common  bile-duct  in  the  terminal  (Vaterian) 
ampulla  (Fig.  99,  A),  so  that  a  gall-stone  arrested 
at  this  point  may  occlude  both  ducts  or  possibly 
cause  a  reflux  of  the  bile  within  the  pancreatic 
duct.  Not  uncommonly  (in  30  per  cent,  of  cases) 
the  ampulla  is  partly  (Fig.  99,  B)  or  completely 
divided  (Fig.  99,  c),  so  that  the  orifices  of  the  two 
ducts  are  separated ;  in  such  cases  'occlusion  of 
the  termination  of  the  bile-passage  leaves  the  pan- 
creatic duct^  free.  An  accessory  duct  (the  duct 
of  Santorini)  is  present  in  a  more  or  less  de- 
veloped condition  in  50  per  cent,  of  subjects.  It 
may  ^  form  .a  connexion  with  the  main  duct,  as 
in  Fig.  99,  A,  or  be  merely  a  minute  ductule,  as  in 


444  ABDOMEN  AND  PELVIS  [(HAP. 

Fig.  99,  B.  t  The  accessory  duct  opens  nearer  the 
pylorus,  being  f  of  an  inch  above  the  ampulla 
of  Vater.  The  ampulla  usually  extends  into  a 
papilla  which  projects  within  the  duodenum,  but 
this  papillated  condition  is  not  always  present. 
Septic  conditions  may  spread  from  the  duodenum 
to  the  pancreas  or  gall-bladder  by  means  of  their 
ducts. 

The  common  bile-duct  in  its  second  stage  lies 
between  the  head  of  the  pancreas  and  the  duo- 
denum. It  thus  happens  that  in  carcinoma  of 
this  part  of  the  gland  the  duct  may  became  en- 


Fig.  99. — Showing   the  variations  in  the  manner  of 
termination  of  the  pancreatic  and  bile-ducts. 

A,  Form  in  which  the  common  bile-duct  (c,  B,  D)  and  main  pan- 
creatic duct  (B)  end  in  an  ampulla  (E).    A,  Accessory  duct :  i. 
ii.,  iii.,  first,  second,  and  third  stages  of  the  duodenum. 

B,  Form  in  which  the  ampulla- is  partly  divided.  The  accessory  duct 

is  shown  in  its  reduced  form. 

C,  Form  in  which  the  common  bile-duct,  and  pancreatic  duct  have 

separate  openings  into  the  duodenum.    The  accessory  is  absent . 

tirely  occluded  and  jaundice  result.  Or  the  duo- 
denum and  even  the  colon  may  be  more  or  less 
obstructed  by  pressure,  or  the  neighbouring 
vessels  be  closed.  Cancer  of  the  pylorus  may 
spread  to  the  head  of  the  pancreas  by  direct 
extension.  The  lymphatics  of  the  two  parts  also 
freely  communicate. 

The  pancreas  lies  behind  the  lesser  sac  of  the 
peritoneum  (bursa  omentalis),  its  anterior  surface 


xix]  THE   KIDNEY  445 

being  covered  by  the  posterior  wall  of  the  sac ; 
it  is  in  front  of  the  aorta,  in  the  fork  between 
the  co3liac  axis  above  and  the  superior  mesenteric 
artery  below.  The  portal  vein  passes  upwards 
behind  the  neck  of  the  gland. 

Islets  of  Langerhans. — When  microscopic  sec- 
tions of  the  pancreas  are  examined,  numerous 
small  groups  of  cells  are  observed  among  the 
normal  acini  of  the  gland.  These  islets  of  Lan- 
gerhans  are  acini  of  the  gland  which  have  become 
modified  to  form  an  internal  secretion  (Swale 
Vincent).  They  vary  in  number  from  300  to  400 
(M.  A.  Lane).  The  pathological  proof  is  now 
definite  that  destruction  of  these  islets  gives  rise 
to  diabetes  (Mayo  Robson). 

The  kidney. — The  relations  of  this  organ  are 
as  follows  (see  Figs.  98,  100)  :  — 

In  front. 

Jtight.  Lejt. 

Visceral  surface  of  liver.  Fundus  of  stomach. 

Second  part  of  duodenum.  Descending  colon. 

Comniencoment  of  transverse  colon.  Pancreas. 

Ascending  colon.  Spleen. 


Liv<>r. 


Kidney. 


Externally. 
Spleen/ 


Behind. 

Lower  part  of  arch  of  diaphragm. 

Quadratus  lumborum.     Psoas.    Transversalis. 

Last  jib  and  transverse  processes  -of  upper  two  lumbar  vertebrae. 

The  kidneys  are  deeply  placed,  and  cannot  be 
felt  or  distinctly  identified  when  normal.  They 
are  most  accessible  to  pressure  at  the  outer  edge 
of  the  erector  spinse,  just  below  the  last  rib  (Figs. 
97  and  100).  The  dullness  of  the  right  kidney 
merges  above  in  that  of  the  liver,  while  on  the  left 
side  it  is  impossible  to  distinguish  between  the 
dullness  of  the  kidney  and  of  spleen.  The  right 
kidney  usually  lies  lower  down  than  does  the  left ; 
but  even  the  lower  pole  of  the  right  kidney  is  an 


446  ABDOMEN  AND  PELVIS  [CHAP. 

inch  above  the  crest  of  the  ilium,  or — what  for 
practical  purposes  is  the  same  level — above  the 
umbilical  line  (Fig.  85,  p.  392).  The  simplest 
manner  of  indicating  the  position  of  a  kidney  is 
to  mark  out  the  position  of  the  upper  and  lower 
pole  and  between  those  two  points  delineate  the 
well-known  form  of  the  kidney.  The  lower  pole 
of  the  right  organ  lies  about  ^  an  inch  outside 
the  prominent  lateral  border  of  the  erector  spinse 
and  1  inch  above  the  iliac  crest  (Fig.  100) ;  since 
the  kidney  is  about  4  inches  long  and  is  situated 
obliquely — its  long  axis  corresponding  to  that 
of  the  twelfth  rib — its  upper  pole  is  sufficiently 
indicated  by  taking  a  point  4  inches  above  and 
1^  inches  internal  to  the  position  of  the  lower 
pole.  The  spine  of  the  eleventh  dorsal  vertebra 
—which  may  be  identified  when  the  patient  bends 
by  its  anticlinal  direction  and  semilumbar  form — 
is  just  below  the  level  of  the  upper  pole.  On  an 
average  the  left  kidney  lies  |  an  inch  higher  than 
the  right  (Addison).  In  many  instances  in  the 
female  the  lower  pole  reaches  the  iliac  crest,  and 
may  even  go  below  it.  Such  positions  are  much 
less  common  in  the  male.  The  hilus^lies  about 
2  inches  from  the  middle  line,  and  is  opposite 
to  the  first  lumbar  spine  and  usually  in  the  gap 
between  the  transverse  processes  of  the  first  and 
second  lumbar  vertebrae  (Fig.  97).  In  radiograms 
of  the  injected  ureter  the  shadow  of  the  pelvis  of 
the  kidney  is  seen  to  fall  across  those  of  the 
transverse  processes  just  mentioned,  and  also  that 
of  the  last  rib  (Fig.  103). 

The  anterior  surface  is  but  slightly  covered  by 
peritoneum,  being  only  in  contact  with  that  mem- 
brane in  such  parts  as  are  not  in  relation  with 
the  cellular  tissue  at  the  back  of  the  colon  and  at 
the  back  of  the  duodenum  or  pancreas  (Fig.  98). 
The  external  border  is  more  closely  in  ^  connexion 
with  the  peritoneum,  while,  the  posterior  surface 
is  quite  devoid  of  that  membrane  (Figs.  97,  98, 
100).  Crossing  the  posterior  surface  of  the  kidney 
obliquely  from  above  downwards  and  outwards 


xix] 


RUPTURE   OF  THE   KIDNEY 


447 


are  branches  of  the  last  dorsal  nerve  and  of 
the  first  lumbar  artery,  together  with  the  ilio- 
hypogastric  and  ilio-inguinal  nerves  (Fig.  100). 

Rupture  of  the  kidney  is  more  often  recovered 
from  than  is  a  like  lesion  of  any  other  of  the 
more  commonly  injured  abdominal  viscera.  This 


p 


\ 


Fig.  100. — Showing  the  relationships  of  the  kidney  and  colon 
in  the  lumbar  region  from  behind.  (Adapted  front 
Merlcel.}* 

PL.,  Lower  line  of  pleura  ;  XI.,  eleventh  rib  ;  XII.,  twelfth  rib  ;  12th 
d.n.,  twelfth  dorsal  nerve ;  1st  l.n.,  ilio-inguinal  and  ilio-hypo- 
gastrie  nerves  ;  A  B.  vertical  line  re  presenting  position  of  descend- 
ing colon  (dose,  c.)  ;  Q.L.,  quadratus  lumborum  ;  E.S.,  erector 
spinae  ;  peritoneum  (perit)  is  shown  reflected  from  the  front  of 
the  kidney  to  the  colon  on  the  right  side. 

*  The  kidneys  are  represented  in  the  position  they  assume  when  the 
body  is  turned  on  its  face  ;  in  the  supine  position  they  fall  inwards  and 
backwards  into  the  position  described  in  the  text.  In  the  subject 
figured  above,  the  twelfth  rib  is  shorter  than  is  common. 


448  ABDOMEN  AND  PELVIS  [CHAP. 

depends  upon  its  extensive  non-peritoneal  surface, 
whereby  the  extravasation  of  blood  and  urine  that 
follows  the  accident  is  very  often  entirely  extra- 
peritoneal.  The  gland  may  be  readily  wounded 
from  behind  or  from  the  loin,  without  the  peri- 
toneum being  injured.  When  the  spinal  column 
is  much  bent  forwards,  the  kidney  lies  in  the 
angle  of  the  bend,  at  a  part  where  the  flexion  of 
the  column  is  the  most  acute.  In  extreme  flexion, 
therefore,  of  the  spine,  it  may  be  squeezed  between 
the  ilium  and  the  lower  ribs.  Thus^  hsematuria 
is  not  uncommon  after  injuries  to  the  back 
associated  with  extreme  bending  of  the  spine 
forwards,  as  when  a  heavy  weight  falls  upon  the 
bowed  shoulders. 

The  kidney  is  embedded  in  a  large  quantity 
of  loose  fatty  tissue  constituting  the  perirenal 
capsule,  and  suppuration  extending  in  this  tissue 
constitutes  a  perinephritic  abscess.  Such  an  ab- 
scess may  be  ^  due  to  disease  of  the  kidney 
itself,  to  affections  of  the  adjacent  parts  (spine, 
colon,  etc.),  or  to  injuries.  The  pus  is  at  first 
in  front  of  the  quadrat'us  lumborum,  and  then 
usually  makes  its  way  through  that  muscle  or 
through  the  lumbar  fascia.  It  then  presents  itself 
at  the  outer  edge  of  the  erector  spinse,  having 
passed  between  the  adjacent  borders  of  the  ex- 
ternal oblique  and  latissimus  dorsi  muscles.  It 
may,  however,  spread  into  the  iliac  fossa,  or 
extend  into  the  pelvis  along  the  loose  connective 
tissue  behind  the  descending  colon  and  rectum, 
or  open  into  the  colon  or  bladder,  or  even  into  the 
lung.  Most  rarely  of  all  does  it  perforate  the 
peritoneum. ^  Renal  abscess  usually  opens  upon 
the  non-peritoneal  surface  of  the  gland.  It  may 
open  into  the  adjacent  colon.  In  one  case  a  renal 
abscess,  due  to  stone,  made  its  way  from  the  right 
kidney  into  the^pyloric  end  of  the  stomach,  so 
that  a  communication  was  established  between 
those  two  organs.  The  perirenal  fat  is  of  much 
surgical  importance,  as  its  laxity  permits  of 
a  ready  enucleation  of  the  organ.  It  is  more 


xix]  MOVABLE   KIDNEY  449 

abundant  behind  than  in  front.  The  fat  is  of 
a  peculiar  oleaginous  nature,  forming  an  elastic, 
mobile  supporting  cushion  in  which  the  kidney 
can  respond  to  the  respiratory  movements  of  the 
diaphragm.  When  this  tissue  has  been  destroyed 
or  modified  by  inflammation,  the  kidney  be- 
comes fixed,  and  its  removal  a  matter  of  great 
difficulty.  This  is  illustrated  by  the  removal 
of  a  large  tuberculous  kidney  which  has  been 
long  diseased.  Besides  the  perirenal  capsule, 
the  kidney  also  possesses  its  proper  capsule, 
which  can  be  easily  stripped  from  the  normal 
organ.  The  blood  pressure  in  the  renal  vessels 
renders  the  capsule  tense;  in  inflammatory  con- 
ditions the  tension  may  become  so  great  as  to 
interfere  with  the  free  passage  of  blood  through 
the  kidney.  Incision  of  the  capsule  has  been 
proposed  to  relieve  such  congested  conditions. 

Movable  kidney.  —  The  kidneys,  ^being  closely 
applied  to  the  diaphragm,  necessarily  follow  its 
respiratory  movements;  in  normal  breathing  the 
up-and-down  excursion  of  the  kidney  is  about 
^  an  inch  in  extent.  The  perirenal  capsule  in 
which  the  kidney  is  loosely  embedded  is  merely 
a  specialized  part  of  the  subperitoneal  connec- 
tive tissue.  The  ^  parts  of  the  perirenal  capsule 
have  been  artificially  separated  into  prenephrir. 
and  postnephric  fascice.  Above,  the  perirenal 
capsule  is  continuous  with  the  dense  subperi- 
toneal tissue  on  the  diaphragm,  externally  with 
the  equally  dense  laver  over  the  transversalis, 
internally  it  fuses  with  the  sheaths  of  the  in- 
ferior vena  cava  and  .aorta,  while  below  it  is 
continued  downwards,  as  the  lax  subperitoneal 
tissue  surrounding  the  ureter,  to  become  con- 
tinuous with  the  corresponding  tissue  in  the 
pelvis.  Hence  only  downward  renal  displace- 
ments are  possible.  The  perirenal  capsule  and 
the  renal  vessels,  while  they  restrict  and  deter- 
mine the  direction  of  the  renal  movements, 
only  come  into  action  when  the  normal  respir- 
atory limits  have  been  exceeded.  The  force 


450-  ABDOMEN  AND  PELVIS  [CHAP. 

which  retains  the  kidneys  in  position  is  the 
intra-abdominal  tension  maintained  by  the  mus- 
culature of  the  abdominal  wall,  by  which  the 
other  viscera  are  compressed  against  the  kidneys. 
With  the  absorption  of  fat  from  the  capsule  the 
tissue  of  the  perirenal  capsule  becomes  more  lax 
and  the  renal  movements  more  unrestrained. 
Hence  movable  kidney  is  often  met  with  in  the 
badly  nourished.  It  is  far  more  common  in 
women  than  in  men.  In  the  former  sex  the  influ- 
ence of  pregnancy  appears  to  have  especial  effect, 
acting,  probably,  by  dragging  upon  the  peri- 
toneum, and  by  loosening  its  connexions,  as  well 
as  by  inducing,  after  delivery,  a  general  laxity 
of  the  abdominal  walls.  The  right  kidney  is  far 
more  often  movable  than  is  the  left,  owing  prob- 
ably to  the  displacing  influence  of  the  liver.  It 
is  not  uncommon  to  find  cases  in  which  a  movable 
kidney  has  pressed  against  the  neck  of  the  gall- 
bladder and  obstructed  the  flow  of  bile.  The 
movable  kidney  can,  of  course,  only  be  displaced 
within  a  segment  of  a  circle  whose  radius  corre- 
sponds to  the  length  of  the  renal  vessels,  and  yet 
this  displacement  may  be  considerable. 

The  dragging  pains  which  are  felt  with  a 
movable  kidney  are  due  to  a  stretching  ofy  the 
renal  plexus,  which  is  connected  with  the  solar 
plexus  and  enters  the  kidney  with  the  arteries. 
The  kidney  receives  its  nerve  supply  from  the 
tenth,  eleventh,  twelfth  dorsal,  and  first  lumbar 
segments  of  the  spinal  cord  through  the  small 
and  lesser  splanchnics  (Head).  Pain  is  referred 
to  the  wall  of  the  abdomen  along  the  sensory 
nerves  derived  from  these  segments. 

Abnormalities  of  the  kidneys. — One,  or  less 
frequently  both  kidneys,  may  be  developed  in 
an  abnormal  position.  The  left  is  more  often 
out  of  place  than  the  right,  and  may  be 
found  over  the  sacro-iliac  synchondrosis,  or  the 
promontory  of  the  sacrum,  or  be  discovered 
in  the  iliac  fossa  or  pelvis.  The  irregularly 
placed  kidney  is  often  misshapen.  The  kidney 


xix]  ABNORMALITIES   OF  KIDNEY  451 

may  exhibit  a  more  or  less  extreme  degree  of 
lobulation,  a  condition  present  in  the  newly  born. 
The  ureter  may  be  double  in  its  upper  part  or 
throughout  its  whole  extent,  there  being  two 
ureteral  orifices  in  the  bladder.  Supernumerary 
arteries  are  frequently  present;  cases  have  been 
recorded  where  such  vessels,  passing  to  the  lower 
pole  of  the  kidney,  have  caused  constriction  or 
kinking  of  the  ureter,  and  hydronephrosis.  In 


POLE  OF  KIDNEY 


RENAL  ART. 


ILATED  PELVIS 


ABNORMAL  ART 


Fig.    101. — An  abnormal   renal  artery  causing  kinking  at 
the     uretero-pelvic     junction,     and     hydronephrosis. 

(After  Hurry  Fenwick.) 

a  series  of  cases  of  hydronephrosis,  Mr.  Hurry 
Fenwick  found  that  the  kinking  of  the  ureter 
was  due  to,  an  abnormal  vessel  in  16  per  cent, 
of  cases  (Fig.  101). 

The  kidneys  are  developed  in  the  pelvic  region, 
and  ascend  in  the  early  months  of  foetal  life  to 
a  lumbar  position.  New  renal  vessels  are  formed 
as  the  ascent  takes  place.  The  "  sacral "  kidney 
is  one  which  has  been  arrested  in  its  ascent,  and 
the  blood  supply  is  drawn  from  the  common  iliac 


452  ABDOMEN  AND  PELVIS  [CHAP. 

arteries.     Double  ureter  is  due  to  a  division  of 
the  primary  renal  bud. 

The  two  kidneys  may  be  fused.  "  The  lowest 
degree  of  fusion  is  seen  in  the  horse-shoe  kidney. 
The  two  kidneys  are  united  at  their  inferior  por- 
tions by  a  flat,  riband-like,  or  rounded  bridge  of 
tissue,  which  crosses  the  vertebral  column.  In  the 
higher  degrees  the  two  lateral  portions  approach 
one  another  more  and  more  until  they  reach  the 
highest  degree,  in  which  a  single  disc-like  kidney 
lying  in  the  median  line,  and  provided  with  a 
double  or  single  calyx,  represents  complete 
fusion  "  (Rokitansky).  When  the  two  kidneys  are 
united  by  a  web  of  connective  tissue,  the  condi- 
tion is  no  bar  to  operation.  There  may  be  an 
entire  absence  of  one  kidney.  The  single  kidney 
may  be  lateral  or  median  in  position.  Sir  Henry 
Morris  gives  the  following  estimate  of  the  fre- 
quency of  these  abnormal  conditions :  Congenital 
absence  or  extreme  atrophy  of  one  kidney  may 
be  expected  in  about  1  in  4,000  cases,  the  horse- 
shoe kidney  in  1  in  1,600,  and  the  single  fused 
kidney  in  1  in  8,000  cases.* 

Operations  on  the  kidney.  —  (1)  Nephrotomy. 
Incision  into  the  kidney  for  exploration,  or  the 
evacuation  of  pus.  (2)  Nephrolithotomy.  In- 
cision into  the  gland  for  the  removal  of  a  calculus. 

(3)  Nephrectomy.     Removal  of  the  entire  organ. 

(4)  Nephrorrhaphy.     The  operation  of  securing  a 
movable  kidney  in   its  normal  position.      In   thr 
first,    second,    and    fourth   operations   the   kidney 
is  reached  through  the  loin.     In  nephrectomy  the 
incision   is  carried  backwards  about  1   inch  over 
the  erector  spinse,    and  a  part  of  the  quadratus 
lumborum   will   be  divided    (see   Fig.    100).     The 
costo-vertebral    ligament,    a    specialized    part    of 
the    middle    layer    of    the    lumbar    fascia    which 
binds    the    last    rib    to    the    tips    of    the    upper 
two    lumbar    transverse    processes,    also    falls    in 
the  line  of  the  incision.     The   perirenal   capsule 

*  For  fuller  details  regarding  abnormalities  of  kidneys,  see  "Urinary 
Surgery,"  by  F.  8.  Kidd. 


xix]  OPERATIONS    ON   KIDNEY  453 

is  opened  up,  and  the  gland  enucleated  from 
the  capsule  of  fat  in  which  it  lies.  In  some 
instances  the  last  rib  has  been  resected  to  ob- 
tain more  space  for  the  operation.  The  pleura 
reaches  the  neck  of  the  twelfth  rib  and  occa- 
sionally it  descends  as  far  as  the  transverse 
process  of  the  first  lumbar  vertebra  (Figs.  97 
and  100).  Not  uncommonly  the  twelfth  rib  is 
so  short  that  it  is  completely  hidden  by  the 
erector  spinse,  and  the  eleventh  rib  appears  to 
be  the  last.  The  pleura  may  be  deliberately 
opened  if  necessary,  and  then  sutured.  If  the 
patient  be  in  a  semi-prone  position  there  is  no 
risk  of  collapse  of  the  lung. 

When  the  kidney  is  free  from  its  fatty  capsule, 
the  vessels  at  the  hilus  are  secured  separately  by 
ligatures.  The  numerous  nerves  to  the  kidney 
are  no  doubt  included  with  the  vessels.  They  con- 
stitute a  surgical  pedicle  of  the  kidney.  At  the 
hilus  the  vein  lies  in  front,  the  artery  and  its 
branches  next,  and  the  ureter  behind  and  towards 
the  lower  part.  The  artery  is  about  the  size  of 
the  brachial,  and  usually  divides  into  four,  five, 
or  six  branches  before  it  reaches  the  kidney. 
This  fact  must  be  borne  in  mind  if  the  structures 
at  the  hilus  are  separately  secured.  One-third 
of  these  branches  constantly  enter  behind  the 
ureter  and  are  liable  to  injury  in  exploration  of 
the  pelvis  of  the  kidney.  The  vein  is  also  repre- 
sented at  the  hilus  by  three  or  four  branches. 
Accessory  renal  arteries  may  be  present.  Some 
may  enter  the  upper  end  of  the  kidney  or  its 
anterior  surface^.  In  removing  large  renal  tumours 
an  abdominal  incision  is  advised,  the  cut  being 
made  either  along  the  corresponding  semilunar 
line,  and  on  a  level  with  the  diseased  mass,  or  in 
the  linea  alba.  The  abdominal  operation  is  the 
more  usual  one ;  it  has  the  advantages  of  greater 
ease  and  rapidity  in  performance,  and  gives  an 
opportunity  for  examining  the  condition  of  both 
kidneys.  In  chronically  inflamed  conditions  of 
the  kidney — as,  for  example,  in  long-standing 


454  ABDOMEN  AND  PELVIS  [CHAP. 

tuberculous  disease — the  kidney  becomes  adherent, 
and  on  the  right  side  is  apt  to  become  closely 
bound  down  to  the  vena  cava.  Much  care  is 
needed  in  clearing  the  great  vein  when  so  ad- 
herent. In  removing  a  very  adherent  kidney  the 
diaphragm  has  been  torn. 

The  suprarenal  bodies  are  situated  at  the 
upper  poles  of  the  kidneys,  but  are  more  closely 
united  to  the  diaphragm  than  to  these  organs, 
as  is  seen  from  the  fact  that  they  are  not  dis- 
placed with  the  kidneys.  The  right  body  lies 
behind  the  right  lobe  of  the  liver,  and  so  close  to 
the  inferior  vena  cava  that  the  two  may  become 
bound  by  inflammatory  adhesions.  They  are  glands 
which  form  an  internal  secretion  (adrenalin)  that 
is  evidently  concerned  in  regulating  the  tonus  of 
non-striated  muscle.  When  applied  directly,  it 
causes  constriction  of  arteries  and  a  narrowing 
of  the  bowel.  The  functional  activity  of  the  gland 
is  regulated  through  its  relatively  large  supply  of 
nerves  (Canon);  after  violent  exertions,  severe  in- 
juries, or  prolonged  operations  its  adrenalin  con- 
tent is  greatly  reduced  or  exhausted.  The  cortex 
of  the  body  is  developed  from  epithelium  covering 
the  Wolffian  body,  and  when  that  body  descends 
with  the  genital  glands,  detached  parts  may  accom- 
pany these  organs  and  form  suprarenal  tumours. 
Parts  may  also  become  embedded  in  the  kidneys 
and  give  rise  to  peculiar  renal  tumours.  The 
medulla,  which  arises  with  the  sympathetic  system, 
receives  a  large  nerve  supply  from  the  solar 
plexus.  Disease  of  the  suprarenals  may  cause 
bronzing  of  the  skin,  and  hence  it  is  believed 
that  they  are  concerned  in  the  formation  of  body 
pigment. 

The  ureters  are  strong  tubes  about  15  inches 
long,  with  thick  muscular  walls,  and  are  placed 
entirely  behind  the  peritoneum.  The  average 
width  is  that  of  a  goose-quill.  The  ureter  rests 
from  above  downwards  upon  (1)  the  psoas  muscle 
and  the  genitp-crural  (genito-femoral)  nerve;  (2) 
the  common  iliac  vessels  on  the  left  side,  and 


xix]  RELATIONS   OF   KIDNEY  455 


ART. 

TRACHEA 
OESOPHAGUS 


[If 

L/uLVErtA  Azvcos  MAJOR 

!/ 

LRlCHT 


RIGHT  KIDNEY 
URETER 
SPERMATIC  VESSELS 

CAVA 

BIFURCATION  OP  AORTA 
CLUTEUS/^EDIUS 
PSOAS 
RECTUM 

SUP.  AIAEMORRH.ART 
GLUTE'US 


Fig.  102. — View  of  the  kidneys,  etc.,  from  behind.   (After 
Riidinyer.) 


456  ABD.OMEN  AND  PELVIS  [CHAP. 

the  external  iliac  vessels  on  the  right  side;  (3) 
after  passing  downwards  on  the  internal  iliac 
artery  it  enters  the  posterior  false  ligament  of 
the  bladder,  and  so  reaches  the  bladder  wall. 
In  the  female  it  passes  through  the  base  of  the 
broad  ligament,  where  the  uterine  artery  loops 
over  it  |  of  an  inch  from  the  neck  of  the  uterus. 
It  rests  on  the  roof  of  the  upper  part  of  the 
vagina  before  entering  the  bladder,  and  a  calculus 
arrested  in  that  stage  may  be  distinctly  felt.  The 
narrowest  part  of  the  tube  is  the  portion  within 
the  bladder  walls  (intramural  part),  and  when 
renal  calculi  pass  along  the  ureter  they  are  often 
arrested  at  this  point.  There  are  two  other  narrow 
points  at  which  the  calculi  may  be  stopped :  at  the 
junction  of  ^  the  tube  with  the  pelvis  of  the  kidney, 
and  where  it  crosses  the  pelvic  brim.  The  ureters 
permit  of  great  distension,  and  in  certain  cases 
of  gradual  dilatation  they  have  attained  a  width 
equal  ^to  that  of  the  thumb  and  even  of  the  small 
intestine.  Several  cases  are  recorded  of  rupture 
of  the  ureter  from  external  violence.  When  such 
an  accident  occurs  a  large  urinary  collection 
usually  forms  behind  the  peritoneum,  which,  lead- 
ing to  suppuration,  will  produce  a  fluctuating 
tumour  beneath  the  parletes.  •> 

The  ureter  expands  in  the  sinus  of  the  kidney 
into  a  funnel-shaped  cavity— the  renal  pelvis. 
This  in  turn  divides  into  the  calyces.  In  the 
pelvis  or  calyces,  calculi  are  .frequently  lodged. 
The  calyces  are  too  narrow  to  admit  an  exploring 
finger.  The  ureter  has  been  successfully  resected 
and  sutured.  It  is  supplied  by  nerves  from 
the  renal  plexus  and  by  vessels  from  the  renal, 
inferior  vesical,  and  subperitoneal  plexus.  The 
muscular  coats  have  a  definite  contractile  rhythm, 
the  point  of  greatest  excitability  being  at  the 
pelvi-ureteral  junction.  Hence,  it  is  at  this  point 
that  peristaltic  waves  commence  and  sweep  the 
urine  droplets  towards  the  bladder.  In  some 
cases  hydronephrosis  is  the  result  not  of  kinking 
but  of  disordered  condition  of  the  rhythm-centre. 


xix] 


COURSE   OF  THE   URETER 


457 


The  malformations  of  the  ureter  have  been  already 
mentioned  (p.  451). 

In  the  search  for  impacted  calculi  by  the  aid 
of  X-rays  the  following  method  will  be  found 
useful  for  indicating  the  course  of  the  ureter : 
The  pelvis  of  the  kidney  lies  between  the  trans- 
verse processes  of  the  two  upper  lumbar  vertebrae 


Fig.  103. — Diagram  to  show  the  course  of  the  ureters  and 
position  of  the  bladder, 

As  they  appear  in  a  skiagram  when  they  have  been  injected  with  a 
bismuth  solution.  The  positions  of  the  fundus  of  the  uterus, 
Fallopian  tubes,  and  ovaries  are  also  indicated. 

(Fig.  103);  its  position  on  the  surface  of  the  body 
may  be  indicated  by  taking  a  point  just  internal 
to  that  used  for  the  gall-bladder  (p.  433).  At 
the  brim  of  the  pelvis  the  ureter  crosses  at  or 
near  the  bifurcation  of  the  common  iliac  artery, 
a  point  which  lies  at  the  junction  of  the  upper 
P* 


458  ABDOMEN  AND  PELVIS  [CHAP. 

with  the  lower  two-thirds  of  a  line  drawn  from 
the  aortic  bifurcation  to  the  femoral  point  (see 
Figs.  102  and  103,  and  81,  p.  367).  Its  pelvic 
course  is  curved  (Fig.  103),  the  convexity  of  its 
outward  bend  lying  |  an  inch  in  front  of  the 
ischial  spine.  The  vesical  orifice  is  to  be  sought 
for  in  a  skiagram  at  some  distance  above  and 
internal  to  the  pubic  spines.  In  searching  for 
calculi  it  is  well  to  remember  that  phleboliths  in 
the  uterine  or  pelvic  veins  and  calcined  remains 
of  pelvic  lymphatic  glands  may  also  give  dense 
shadows.  Mr.  Rigby  has  shown  that  the  ureter 
may  be  exposed  from  behind  through  the  sacro- 
sciatic  notch,  and  calculi  thus  removed  from  it, 
when  the  anterior  operation  is  impracticable  on 
account  of  pelvic  adhesions.  He  uses  the  ischial 
spine  as  a  guide  in  finding  the  ureter. 

Nerve  supply  of  the  abdominal  visrera. 
— Some  account  has  been  given  of  the  nerves  which 
supply  the  abdominal  viscera  and  of  the  spinal 
segments  from  which  they  are  derived  (p.  362). 
These  viscera  are  mainly  supplied  by  the  sympa- 
thetic system  through  a  Aeries  of  plexuses.  The 
most  important  of  these  is  the  solar,  which  sends 
extensions  to  the  stomach,  liver,  spleen,  kidneys, 
suprarenal  capsules,  pancreas,  and  such  parts 
of  the  intestine  as  are  in  connexion  with  the 
superior  mesenteric  artery.  The  solar  plexus 
and  its  ganglia  receive  the  splanchnic  nerves 
and  some  branches  from  the  vagus,  while  com- 
munications from  the  phrenic  go  to  the  hepatic 
and  suprarenal  plexuses.  Through  these  nerves 
the  calibre  of  the  blood-vessels  and  the  amount 
of  b^od  in  the  abdomen  are  regulated:  They 
contain  not  only  the  afferent  or  sensory  fibres 
for  the  abdominal  viscera,  but  also  efferent  or 
constrictor  and  dilator  fibres  for  the  bowel.  It 
may  be  well  understood  that  an  impression 
brought  to  bear  upon  extensive  networks  with 
such  wide  peripheral  and  central  connexions  and 
with  such  important  relations  to  vital  organs 
would  produce  considerable  effects.  These  effects 


xix]  "SYMPATHETIC"   PAINS  459 

we  see  in  the  profound  collapse,  vomiting,  and 
other  grave  symptoms  that  attend  severe  injuries 
to  the  viscera,  and  especially  to  those  that  are  the 
most  directly  associated  with  these  large  plexuses. 
The  distal  parts  of  the  transverse,  descending, 
iliac,  and  pelvic  colons  are  supplied  by  the 
inferior  mesenteric  plexus  as  well  as  important 
fibres  from  the  pelvic  plexus.  The  proximal 
part  of  the  colon,  although  supplied  by  the 
superior  mesenteric  plexus,  is  only  supplied  by 
that  part  of  it  that  is  most  remote  from  the  great 
centres,  and  it  is  a  conspicuous  fact  that  the 
nearer  the  lesion  is  to  the  stomach,  the  graver- 
other  things  being  equal — are  the  nervous  pheno- 
mena produced.  The  most  urgent  symptoms  arise 
in  the  parts  dominated  by  the  vagi. 

In  some  diseases  of  the  liver  and  stomach 
"  sympathetic  "  or  referred  pains  are  complained  of 
between  the  shoulders  or  about  the  inferior  angles 
of  the  scapulae.  They  commonly  appear  some  dis- 
tance below  the  angle  of  the  scapula.  The  nerves 
for  the  stomach  are  derived  principally  from  the 
seventh  and  eighth,  and  those  for  the  liver  from 
the  eighth  and  ninth  spinal  segments.  The  skin 
areas  of  these  segments  may  become  tender  when 
the  organs  are  diseased,  and  to  some  point  in 
these  areas  pain  is  referred  (Fig.  79,  p.  359).  The 
shoulder-tip  pain  that  often  accompanies  liver 
disease  is  situated  in  the  area  supplied  by  the 
fourth  cervical  segment,  the  same  segment  as 
supplies  sensory  fibres  to  the  diaphragm  and 
subdiaphragmatic  connective  tissue  through  the 
phrenic  nerves.  It  will  be  remembered  that  these 
nerves  are  distributed  on  the  under-surface  of 
the  diaphragm,  and  become  affected  in  disordered 
conditions  of  the  liver. 

There  would  seem  to  be  but  little  connexion 
between  a  disease  in  the  sigmoid  flexure  (pelvic 
colon)  and  a  pain  in  the  knee,  yet  in  cases  of 
cancer  in  this  flexure,  and  in  instances  where  it 
has  been  distended  with  faeces,  such  pain  has  been 
complained  of.  The  pain  is  conveyed  along  the 


460  ABDOMEN  AND  PELVIS  [CHAP. 

obturator  nerve,  which  lies  beneath  the  sigmoid 
flexure  and  could  be  readily  pressed  upon  by  the 
gut  when  diseased.  Pain  arising  from  the  small 
intestine  is  usually  referred  to  the  neighbourhood 
of  the  umbilicus — the  distribution  of  the  tenth 
dorsal  nerve  (Fig.  79,  p.  359).  It  seems  remark- 
able that  such  pains  should  be  restricted  to  so 
narrow  an  area,  but  a  full  explanation  of  this 
is  to  be  found  in  the  fact  that  the  whole  of  the 
small  intestine  arises  from  an  extremely  small 
part  of  the  embryonic  alimentary  tract.  Pains 
along  the  groin  (along  the  twelfth  dorsal  and  first 
lumbar  nerves)  arise  from  many  sources — from 
disease  of  the  kidney,  ureter,  ovary,  testicles, 
Fallopian  tubes,  uterus,  appendix,  hip-joint,  and 
from  hernise.  Hence  a  pain  referred  to  this  region 
requires  that  all  these  parts  should  be  investigated 
as  to  the  source  of  the  disease. 

Blood  -  vessels  of  the  abdomen.— Some 
of  the  visceral  branches  of  the  abdominal  aorta 
are  of  large  size,  and  would  bleed  very  copiously 
if  wounded.  Thus,  the  cceliac  axis  and  the 
superior  mesenteric  artery  are  as  large  as  the 
common  carotid ;  the  splenic,  hepatic,  and  renal 
vessels  are  about  the  size  of  the  brachial ;  while 
the  largest  part  of  the  inferior  mesenteric  trunk 
has  dimensions  equal  to  those  of  the  ulnar  artery. 
Aneurysms^of  the  aorta  are  especially  apt  to  occur 
at  the  creliac  axis,  that  being  a  point  where  a 
number  of  large  branches  are  abruptly  given  off, 
and  where  the  course  of  the  circulation  undergoes 
in  consequence  a  sudden  deviation.  Although 
two,  or  in  some  places  three,  anastomotic  arches 
occur  between  the  branches  of  the  superior  mesen- 
teric artery  before  they  form  a  final  network  in 
the  bowel,  yet  embolism  of  a  comparatively  small 
branch  may  lead  to  gangrene  of  the  gut  (Lock- 
wood). 

When  it  is  remembered  that  the  lumbar  glands 
lie  about  the  vena  cava  and  iliac  veins,  it  will 
be  understood  that  great  enlargement  of  those 
bodies  may  cause  oedema  from  pressure.  Gan- 


xix]  ABDOMINAL   BLOOD-VESSELS  461 

grene  of  the  whole  of  the  small  intestine  may 
result  from  an  embolism  of  the  portal  vein.  In 
a  case  reported  by  Mr.  Barnard  the  embolism  was 
caused  by  an  inflammatory  constriction  at  the 
point  where  the  vein  passes  behind  the  neck  of 
the  pancreas.  The  inferior  vena  cava  has  been 
ligatured  successfully;  amongst  the  collateral 
veins  which  enlarge,  the  chief  are  the  azygos, 
epigastric,  and  intravertebral  veins.  Recently 
Prof.  Shattock  has  reported  a  remarkable  case 
of  complete  occlusion  of  the  inferior  vena  cava— 
the  case  of  the  late  Dr.  W.  Rivers  Pollock.  As  a 
young  man  Dr.  Pollock  won  the  inter-university 
120  yards  hurdle  race  in  16  seconds,  making  a 
record.  He  held  his  breath  throughout  the  race, 
and  collapsed  when  the  tape  was  passed.  Holding 
the  breath  dams  the  blood  back  in  the  great 
veins;  the  heart  and  pulsating  muscles,  in  such 
a  race,  must  force  the  blood  onwards  into  the 
great  venous  trunks,  with  the  result  that  the  in- 
ferior vena  cava  becomes  overdistended,  damaged, 
perhaps  thrombosed,  and  then  finally  occluded. 
Gradually  the  veins  leading  from  the  groin  to  the 
axilla  and  breast  become  distended  and  varicosed, 
thus  taking  the  place  of  the  inferior  vena  cava. 
All  his  life  long  Dr.  Pollock  remained  an  invalid 
and  had  to  wear  elastic  supports.  The  renal 
veins  were  also  occluded,  but  communications 
between  the  renal  and  subperitoneal  veins  opened 
up,  the  kidneys,  however,  never  working  as  in 
health. 

A  number  of  minute  but  most  important  anas- 
tomoses exist  between  some  of  the  visceral  branches 
of  the  abdominal  aorta  and  certain  of  the  vessels 
supplied  to  the  abdominal  parietes.  These  anasto- 
moses are  situated  in  the  subperitoneal  tissue  and 
mostly  concern  such  viscera  as  have  a  fair  sur- 
face uncovered  by  that  membrane.  The  viscera 
branches  that  join  the  anastomoses  are  derived 
from  the  hepatic,  renal,  and  suprarenal  arteries, 
and  from  the  vessels  supplying  the  lower  part  of 
the  duodenum,  the  pancreas,  the  caecum,  and  the 


462  ABDOMEN  AND  PELVIS  [CHAP. 

ascending  and  descending  segments  of  the  colon. 
The  parietal  vessels  joining  with  the  above  are 
derived  from  the  phrenic,  lumbar,  ilio-lumbar, 
lower  intercostal,  epigastric,  and  circumflex  iliac 
trunks.  In  a  case  detailed  by  Prof.  Chiene  the 
cceliac  axis  and  mesenteric  vessels  were  plugged, 
but  blood  in  sufficient  amount  to  supply  the 
viscera  had  reached  branches  of  these  arteries 
through  their  parietal  communications. 

In  obstruction  of  the  portal  circulation  that 
is  owing  to  disease  of  the  liver,  blood  from  the 
portal  vein  may  pass  into  the  systemic  veins 
at  the  following  points  (Fig.  104) :  (1)  Lower 
part  of  the  rectum,  from  the  superior  to  the 
inferior  and  middle  hsemorrhoidal  veins;  (2)  at 
the  oesophagus,  from  the  coronary  to  the  oeso- 
phageal  veins;  (3)  in  the  falciform  ^  and  round 
ligaments,  from  the  portal  vein  to  tributaries  of 
the  epigastric;  (4)  in  the  subperitoneal  tissue  of 
the  posterior  wall  of  the  abdomen,  whereby  the 
renal,  phrenic,  lumbar,  and  intercostal  veins  re- 
ceive blood  from  mesenteric,  pancreatic,  and  other 
veins.  By  bringing  about  adhesions  between  the 
omentum  or  visceral  peritoneum  and  the  parietal 
peritoneum,  as  is  done  in  the  Talma-Morrison 
operation,  new  and  large  communications  are 
formed  between  the  portal  and  systemic  venous 
circulations.  Cases  have  been  recorded  of  com- 
munications between  the  external  iliac  vein  and 
the  portal  vein.  These  have  generally  been 
effected  by  the  deep  epigastric  vein^  joining  with 
a  pervious  umbilical  vein  in  the  vicinity  of  the 
navel. 

Thoracic  cluct.  —  The  thoracic  duct  may  be 
wounded  in  the  course  of  removing  tubercular 
glands  from  beneath  the  lower  part  of  the  left 
Bterno-mastoid;  or,  as  in  some  reported  cases,  may 
be  severed  by  a  stab  in  the  neck.  In  each  case 
lymph  and  chyle  in  large  quantities  escaped 
from  the  wound.  The  duct  has  been  found  to 
have  been  obliterated,  and  that,  top,  without  pro- 
ducing any  marked  symptoms  during  life.  It  1ms 


XIX] 


THORACIC   DUCT 


463 


been  cut  and  ligatured  during  removal  of  glands 
from  the  supraclavicular  triangle,  with  no  bad 
result.  Mr.  Leaf  has  shown  that  the  thoracic 


UMBILICUS 

PARUMBILJCAL.  VEIN 


SUPERFICIAL. 
EPIGASTRIC 


PHRENIC     V. 
TO  AZYGOS   VEINS 


CE.SOPHAGEAL  PLANE 


CORONARY    V. 
SPLEN/C    V, 


TO  RENAL  VEINS 


INF.  H/EMORRH. 


Fig.  104. — To  show  the  sites  at  which  communications 
occur  between  the  portal  and  systemic  circulations. 
(After  J.  S.  B.  Stopfortf.) 


464  ABDOMEN  AND  PELVIS 

duct  communicates  freely  with  the  azygos  veins 
in  the  posterior  mediastinum  and  with  the  lym- 
phatic vessels  of  the  right  side  of  the  thorax  and 
neck.  It  frequently  serves  as  a  channel  for  the 
spread  of  malignant  tumours  situated  in  the 
upper  part  of  the  abdomjen.  Enlargement  of 
the  inferior  deep  cervical  glands  in  the  left  side 
of  the  neck  may  be  the  first  sign  of  cancer  of  the 
stomach  (W.  M.  Stevens), 


CHAPTER    XX 
THE    PELVIS    AND    PELVIC    VISCERA 

mechanism  of  the  pelvis.— Besides  forming 
a  cavity  for  certain  viscera,  a  support  for  some 
abdominal  organs,  and  a  point  for  the  attach- 
ment of  the  lower  limb  and  of  many  muscles, 
the  pelvis  serves  to  transmit  the  weight  of  the 
body  both  in  the  standing  and  sitting  postures. 
The  transmission  is  effected  through  two  arches, 
one  available  for  the  erect  position,  the  other  for 
the  posture  when  sitting.  In  the  standing  posture, 
the  arch  is  represented  by  the  sacrum,  the  sacro- 
iliac  joints,  the  acetabula,  and  the  masses  of 
bone  extending  between  the  two  last-named  points. 
If  all  other  parts  of  the  pelvis  were  to  be  cut 
away  but  these,  the  portions  left  would  still  be 
able  to  support  the  weight  of  the  body,  and  would 
represent  in  its  simplicity  the  arch  through  which 
that  weight  is  transmitted.  In  the  sitting  position, 
the  arch  is  represented  by  the  sacrum,  the  sacro- 
iliac  joints,  the  tubera  ischiorum,  and  the  strong 
masses  of  bone  that  extend  between  the  two  last- 
named  parts.  Sir  Henry  Morris  terms  these  two 
arches  the  femoro-sacral  and  the  ischio-sacral.  On 
examining  the  innominate  bone  it  will  be  seen  that 
its  thickest  and  strongest  parts  are  such  as  are 
situate  in  the  line  of  these.  "When  very  consider- 
able strength  is  requisite  in  an  arch,  it  is  continued 
into  a  ring  so  as  to  form  a  counter-arch,  or  what 
is  called  a  tie  is  made  to  connect  together  the 
ends  of  the  arch,  and  thus  to  prevent  them  from 
starting  outwards.  .  .  .  The  body  and  horizontal 
rami  of  the  pubes  form  the  tie  or  counter-arch 
of  the  femoro-sacral,  and  the  united  rami  of 
465 


466  ABDOMEN  AND  PELVIS  [CHAP. 

the  pubes  and  ischium  the  tie  of  the  ischio-sacral 
arch.  .  .  .  This  explains  how  it  is  that  so  much 
strain  is  made  upon  the  symphysis  when  any 
increased  weight  has  to  be  supported  by  the  pelvis, 
as  in  pregnancy;  why  there  is  such  powerlessness, 
with  inability  to  stand  or  sit,  in  cases  in  which 
this  joint  is  weakened  or  diseased;  and  why  the 
anterior  portion  of  the  pelvis  yields  under  the 
weight  of  the  body  and  becomes  deformed  in 
rickets  and  mollities  ossium.;;  *  The  pelvic  de- 
formity in  rickets,  it  may  be  here  observed,  varies 
greatly  according  to  the  age  at  which  the  disease 
sets  in,  and  the  usual  attitude  of  the  child  when 
it  becomes  affected.  In  the  common  form  of 
rickety  pelvis  the  two  acetabula  approach  one 
another,  the  anterior  part  of  the  pelvis  yields,  so 
that  the  symphysis  is  pushed  forward,  and  the 
cavity  becomes  greatly  narrowed  in  its  transverse 
diameter.  In  severe  cases  the  pubic  arch  may 
practically  collapse,  and  the  horizontal  rami 
become  almost  parallel  to  one  another. 

In  the  erect  attitude  the  pelvis  is  so  inclined 
that  the  plane  of  the  brim  of  the  true  pelvis  forms 
with  the  horizon  an  angle  of  from  60°  to  65°;  the 
base  of  the  sacrum  is  about  3|  inches  above  the 
upper  border  of  the  symphysis,  while  the  tip  of 
the  coccyx  is  a  little  higher  than  its  lower  border. 
The  centre  of  gravity  of  the  whole  body  (adult) 
is  at  a  spot  just  above  the  lumbo-sacral  angle, 
and  exactly  over  the  mid-point  of  a  line  drawn 
between  the  heads  of  the  femora. 

Fractures  of  the  pelvis. — From  what  has 
been  already  said,  it  may  be  surmised  that  the 
weakest  parts  of  the  pelvis  are  at  the  symphysis 
and  the  sacro-iliac  joints.  The  bones  of  these 
parts,  however,  are  so  very  firmly  knit  together 
by  powerful  ligaments  that  it  is  very  rare  for 
these  articulations  to  give  way,  fracture  of  the 
adjacent  bones  being  more  common.  The  com- 
monest fracture  of  the  pelvis  is  in  the  weak 

*  Sir  ITonry  Morris,    "  The  Joints,"  p.    110,    where  a  most   valuable 
acf-ount  of  the  mechanism  of  the  pelvis  will  he  found. 


xx]  FRACTURES   OF  THE  PELVIS  467 

counter-arch,  and  involves  the  rami  of  both  the 
pubes  and  the  ischium.  The  fracture  is  often 
associated  with  some  tearing  of  ligaments  about 
the  sacro-iliac  joint,  and  is  met  with  in  acci- 
dents due  to  the  most  varied  forms  of  violence. 
This  last  remarkable  circumstance  is  thus  ex- 
plained by  Tillaux.  If  (a)  the  pelvis  be  com- 
pressed in  an  antero-posterior  direction,  the  main 
brunt  of  the  force  conies  upon  the  weak  counter- 
arch,  which  fractures  from  direct  violence.  The 
force,  continuing,  tends  to  push  asunder  the  two 
iliac  bones,  and  so  cause  rupture  of  the  anterior 
ligaments  at  the  sacro-iliac  joint.  If  (6)  the  force 
be  applied  transversely,  the  two  acetabula  tend 
to  be  pressed  towards  one  another,  the  counter- 
arch  becomes  more  bent,  and  ultimately  gives 
way  by  indirect  violence.  The  violence,  continu- 
ing, forces  the  two  ilia  towards  one  another;  the 
strain  then  falls  upon  the  sacro-iliac  joint,  and 
the  posterior  ligaments  of  that  joint  are  apt  to 
yield,  or  portions  of  the  bone  adjacent  to  the  joint 
are  torn  away.  In  cases  of  falls,  when  the  patient 
alights  upon  the  feet  or  ischial  tuberosities,  it 
can  be  understood  how  in  many  instances  the  main 
arches  will  escape  injury  owing  to  their  great 
strength,  while  the  counter-arch  becomes  frac- 
tured. Any  part  of  the  pelvis,  including  the 
sacrum,  may  be  broken  by  well-localized  direct 
violence.  More  or  less  of  the  iliac  crest,  the 
anterior  superior  and  posterior  superior  spines, 
have  been  knocked  off.  The  first-named  part  may 
be  separated  as  an  epiphysis.  It  joins  the  bone 
at  about  the  twenty-fourth  year.  In  one  case  the 
anterior  inferior  spinous  process  was  torn  off  by 
the  rectus  muscle  during  the  act  odt  running  a 
race.  The  os  innominatum  has  been  broken  into 
its  three  anatomical  portions.  This  accident  can- 
not take  place  after  about  the  seventeenth  year, 
since  by  that  time  the  Y-shaped  cartilage  is 
usually  fully  ossified,  and  the  three  elementary 
bones  are  fully  united  in  the  acetabulum.  Before 
such  consolidation  occurs,  abscess  in  the  hip- 


468  ABDOMEN  AND  PELVIS  [CHAP. 

joint  not  infrequently  makes  its  way  through 
the  cartilage  into  the  pelvis.  The  acetabulurn 
has  been  fractured,  and  the  head  of  the  femur 
driven  through  its  thinnest  part  into  the  pelvis. 
In  fractures  of  the  pubes  and  ischium  the  bladder 
has  been  torn  by  the  sharp  fragments.  In  one 
case  a  loose  piece  of  bone  that  had  been  driven 
into  the  bladder  became  the  nucleus  for  a  stone. 
The  urethra  and  vagina  also  have  been  lacerated 
or  seriously  compressed  by  the  displaced  bones. 
In  fractures  of  the  sacrum  the  rectum  has  been 
torn,  or  has  been  so  compressed  by  the  lower 
fragment  (which  is  almost  always  carried  for- 
wards) as  to  be  nearly  closed. 

Sympliysis  pubis. — Separation  of  the  bones 
at  the  symphysis  without  fracture  has  occurred 
from  severe  violence.  Malgaigne  reports  three 
cases  where  the  separation  was  brought  about 
by  muscular  violence  only,  by  extreme  action 
of  the  adductor  muscles  of  the  two  sides.  The 
symphysis  pubis  may  be  divided  in  cases  of 
contracted  pelvis,  with  the  object  of  obtaining 
more  room  during  labour,  and  of  so  avoid- 
ing Csesarean  section.  The  union  consists  of 
fibro-cartilage  and  transverse  peripheral  fibrous 
bands.  It  varies  ^  in  depth  from  1|  to  If  inches, 
and  may  be  divided  subcutaneously,  when  the 
bones  gape  quite  i  an  inch.  It  has  been  shown, 
however,  that  to  gain  ^  an  inch  in  the  antero- 
posterior  diameter  the  bones  must  be  separated  to 
the  extent  of  2  inches.  Such  a  separation  involves 
laceration  of  the  sacro-iliac  ligaments,  and  damage 
to  the  attachments  of  the  pelvic  viscera. 

The  sacro-iliac  joint  may  be  the  seat  of 
disease.  Normally,  there  are  a  synovial  space  and 
a  slight  degree  of  movement  in  this  joint.  As  the 
articulation  lies  in  the  line  of  the  great  arches  of 
the  pelvis,  it  follows  that,  when  inflamed,  much 
pain  is  felt,  both  when  the  patient  is  standing  and 
when  sitting,  and  particularly  when  an  attempt 
is  made  to  turn  the  body  on  the  pelvis.  When 
abscess  forms  it  tends  to  come  forwards,  owing 


xx]  SACRO-ILIAC  JOINT  469 

to  the  anterior  ligament  being  slight  while  the 
posterior  ligament  is  dense,  thick,  and  of  great 
strength.  Having  reached  the  pelvic  aspect  of  the 
joint,  the  pus  may  occupy  the  iliac  fossa,  or  gain 
the  ilio-psoas  sheath.  Or  it  may  follow  the  lumbo- 
sacral  cord  and  great  sciatic  nerve  and  point  in 
the  thigh  behind  the  great  trochanter ;  or  it  may 
be  guided  by  the  obturator  vessels  to  the  inner  side 
of  the  thyroid  foramen,  and  ultimately  appear  at 
the  inner  side  of  the  thigh.  The  abscess  may, 
however,  proceed  backwards,  and  point  over  the 
posterior  aspect  of  the  joint.  The  joint  cannot 
be  approached  from  behind  because  of  its  depth 
and  the  strength  and  thickness  of  its  posterior 
ligaments.  It  is  best  exposed  from  the  gluteal 
region  by  an  incision  which  runs  nearly  parallel 
to,  but  some  2  inches  below,  the  posterior  half 
of  the  iliac  crest.  The  gluteal  muscles  and  fascia 
are  cut  through  until  the  ilium  is  exposed  and 
the  upper  margin  of  the  sciatic  notch  made  out 
by  the  surgeon's  finger.  The  joint  is  exposed 
(see  Fig.  115,  p.  525)  by  trephining  the  ilium  at 
the  mid-point  of  a  line  drawn  from  the  anterior 
border  of  the  sciatic  notch  to  a  point  at  the 
junction  of  the  posterior  and  middle  thirds  of 
the  iliac  crest  (Wheeler). 

The  nerve  relations  of  this  joint  are  important. 
It  is  supplied  by  the  superior  gluteal,  by  the 
lumbo-sacral  cord  and  the  first  sacral  nerve,  and 
by  the  first  and  second  posterior  sacral  nerves 
(Morris).  The  lumbo-sacral  cord  and  the  obtura- 
tor nerve  pass  over  the  front  of  the  joint,  the 
former  being  very  closely  connected  with  the 
articulation.  It  will  be  understood  from  these 
relations  that  in  sacro-iliac  disease  pain  is 
felt  over  the  sacral  region  (upper  sacral  nerves) 
and  in  the  buttock  (gluteal  nerve).  Much  pain 
is  also  often  complained  of  in  the  hip-  or  knee- 
joint,  and  along  the  inner  part  of  the  thigh 
(obturator  nerve).  In  one  or  two  reported  cases 
there  has  been  severe  pain  in  the  calf  and  back  of 
the  thigh,  with  painful  twitchings  in  the  muscles 


470  ABDOMEN  AND  PELVIS  [CHAP. 

of  those  parts  (lumbo-sacral  cord  and  connexion 
with  the  great  sciatic  nerve).  Dislocation  of  the 
sacrum  afc  this  joint  is  prevented  by  the  remark- 
able double  wedge-shaped  outline  of  the  bone,  and 
by  the  very  dense  ligaments  that  bind  it  in  its 
place.  t  The  bone  is  set  very  obliquely,  so  that 
the  weight  of  the  body  tends  to  force  its  base  into 
the  pelvis  and  tilt  its  apex  upwards.  The  strong 
posterior  sacro-iliac  ligaments  prevent  the  first 
movement,  the  great  sacro-sciatic  the  second. 

Sacro  -  coccygeal  tumour*.  —  The  sacro- 
coccygeal  region  is  very  often  the  seat  of  con- 
genital tumours.  To  this  part  of  the'  pelvis  has 
also  been  found  attached  a  third  lower  limb, 
leading  to  the  condition  known  a-s  "tripodism." 
Parasitic  foetuses  have  also  frequently  been  found 
attached  to  this  segment  of  the  spine.  In  many 
of  the  instances  of  attached  foetuses  the  two 
individuals  have  been  joined  together  at  this 
part  of  the  column.  Some  of  the  saero-coccygeal 
tumours  contain  epithelial  cysts  and  fragments  of 
skin,  muscle,  nerve,  bone,  cartilage,  and  mucous 
membrane.  These  strange  masses  spring  from  the 
anterior  part  of  the  coccyx,  between  it  and  the 
rectum.  By  some  they  are  supposed  to  arise  from 
the  coccygeal  body,  by  others  ( Bland- Button) 
from  the  structures  known  to  embryologists  as 
the  postanal  gut  and  the  neurenteric  passage. 

The  sacro-coccygeal  joint  may  be  dislocated 
or  diseased.  In  either  affection  great  pain  is  kept 
up  from  the  frequent  movement  of  the  part  by  the 
muscles  attached  to  the  coccyx  (the  gluteus  maxi- 
mus,  coccygeus,  levator  ani,  and  sphincter).  In 
the  luxation  the  bone  may  project  into  the  rectum, 
and  thus  give  trouble.  The  joint  and  the  parts 
about  it  may  be  the  seat  of  such  severe  neuralgia 
("coccygodynia")  as  to  require  excision  of  the 
coccyx,  or  a  free  division  of  the  structures  that 
cover  it  behind.  The  joint  and  the  fibrous  tissue 
about  it  are  supplied  by  the  following  nerves : 
the  posterior  divisions  of  the  second,  third,  and 
fourth  sacral,  and  the  anterior  and  posterior 


xx]  FLOOR   OF   THE   PELVIS  471 

divisions  of  the  fifth  sacral  and  coccygeal.  In  old 
age  the  coccyx  becomes  ossified  to  the  sacrum. 

Floor  of  the  pelvis  and  the  pelvic 
fascia.— The  outlet  of  the  bony  pelvis  is  occu- 
pied in  the  recent  state  by  the  following  struc- 
tures, from  behind  forwards:  the  pyriformis,  the 
sacro-sciatic  ligaments,  the  coccygeus,  the  levator 
ani  (by  far  the  most  important  element),  and 
the  triangular  ligament  of  the  perineum.  These 
form  the  floor  or  diaphragm  of  the  pelvis.  The 
three  structures  last  named  separate  the  pelvic 
cavity  from  the  perineum  and  provide  a  muscular 
hammock  for  the  support  of  the  pelvic  viscera. 

Apertures  in  the  pelvic  floor.— The  pubq-coc- 
cygeal  fibres  of  the  right  and  left  levator  ani  are 
separated  by  a  narrow  cleft  which  extends  from 
the  symphysis  pubis  to  the  ano-coccygeal  body. 
Through  this  cleft  or  raphe  pass  the  apertures 
of  the  pelvic  floor,  the  anal  canal,  the  vagina, 
and  the  urethra.  The  length  of  the  cleft  is 
about  If  inches;  in  defaecation  the  fibres  of  the 
levator  ani  are  relaxed  and  the  anal  canal  moves 
backwards  and  downwards  so  that  the  cleft  is 
elongated  about  \  an  inch  (R.  H.  Paramore). 
In  parturition  the  vaginal  aperture  becomes 
greatly  distended  by  the  passage  of  the  foetal  head. 
In  muscular  efforts,  when  the  musculature  of  the 
abdominal  wall  is  also  contracted,  the  cleft  or 
raphe  is  shortened  by  the  contraction  of  the 
pubo-coccygeal  fibres,  the  anal  canal^  being  pulled 
towards  the  symphysis.  The  cleft  is  also  filled, 
between  the  anal  canal  and  the  uro-genital  passage, 
by  the  perineal  body.  Between  the  adjacent  bor- 
ders of  the  right  and  left  pubo-coccygeal  muscles 
the  intervening  tissue  contains  much  non-striated 
muscle.  Anteriorly  the  cleft  is  strengthened  by 
the  triangular  ligament;  the  mesial  pubo-coccygeal 
fibres  lie  on  this  ligament.^ 

Pelvic  fascia.— The  pelvic  fascia  is  a  complex 
structure  made  up  of  the  following  parts  :  (1) 
muscular  sheaths ;  (2)  visceral  sheaths  or  capsules ; 
(3)  vascular  sheaths;  (4)  arcuate  ligament  of 


472  ABDOMEN  AND  PELVIS  [CHAP. 

the  leyator  ani.  The  muscular  sheaths  are  the 
following  :  (1)  The  obturator  fascia,  which  covers 
the  pelvic  aspect  of  the  obturator  interims  and 
is  attached  to  the  interior  of  the  pelvis  round 
the  origin  of  the  muscle;  (2)  the  fibrous  sheet 
on  the  pelvic  aspect  of  the  pyriformis,  in  which 
are  embedded  the  internal  iliac  vessels  and  sacral 
nerves;  (3)  the  sheath  of  the  levator  ani— the 
layer  on  its  perineal  aspect  is  known  as  the 
anal  fascia,  the  stratum  on  its  pelvic  aspect  as 
the  visceral  layer  of  fascia;  (4)  the  triangular 
ligament,  which  is  the  fibrous  tissue  enclosing  the 
constrictor  urethrse  and  affording  a  firm  attach- 
ment to  the  bulb  of  the  penis  (Elliot  Smith).  The 
visceral  sheaths  are  :  (1)  the  sheath  of  the  prostate; 
(2)  the  sheath  of  the  vagina;  (3)  the  sheath  of  the 
rectum.  These  fibrous  coverings  of  the  organs 
which  rest  on  the  muscular  floor  of  the  pelvis 
fuse  with  the  visceral  layer  on  the  upper  surface 
of  the  levator  ani  and  with  the  peri  vascular 
sheaths.  ^  The  perivascular  sheaths  are  :  (1)  the 
fibrous  tissue  surrounding  the  visceral  branches 
of  the  internal  iliac  artery — the  uterine,  vesical, 
prostatic,  and  hsemorrhoidal —  and  round  the 
pelvic  plexus  of  nerves  (part  of  this  tissue  has 
been  described  under  the  name  of  the  suspensory 
ligament  of  the  pelvic  viscera — A.  M.  Paterson)  ; 
(2)  the  fibrous  sheath  surrounding  the  internal 
pudic  vessels,  of  which  Alcock's  canal  is  a  part. 
The  arcuate  tendon  of  the  levator  ani  is  the 
structure  formerly  described  as  the  white  line. 
It  is  a  strong  band  of  fibrous  tissue  passing 
backwards  from  the  posterior  aspect  of  the  pubis, 
near  the  lower  border  of  the  symphysis,  to  the 
inner  aspect  of  the  pelvis,  near  the  ischial  spine 
on  the  inner  surface  of  the  obturator  fascia. 
From  this  tendinous  band  many  fibres  of  the 
levator  ani  arise ;  the  suspensory  or  perivascular 
ligament  is  also  supported  from  it.  Its  middle 
part  is  often  free,  so  that  one  can  slip  a  finger 
downwards  between  the  arcuate  ligament  and  the 
obturator  fascia;  a  hernia  may  occur  here.  The 


xx]  PELVIC  VISCERA  473 

muscular  and  vascular  sheaths  unite  at  their 
points  of  contact;  thus  the  pelvic  diaphragm  and 
viscera  are  welded  into  a  united  complex  structure. 
Fixation  and  movements  of  the  pelvic 
viscera. — The  pelvic  viscera  are  liable  to  dis- 
placement; a  knowledge  of  how  they  are  fixed 
and  kept  in  position  affords  the  only  basis  of 
a  sound  treatment.  The  bladder,  rectum,  and 
uterus  must  be  so  lodged  that  they  can  fill  and 
empty ;  they  must  be  so  supported  that  they  can 
withstand  the  violent  movements  and  pressures 
to  which  all  the  abdominal  viscera  are  subject 
during  active  muscular  and  respiratory  efforts. 
To  allow  a  free  visceral  movement,  the  parietal 
pelvic  peritoneum  is  loosely  attached,  but  over 
the  bladder,  uterus,  and  rectum  this  membrane 
is  firmly  bound  down.  Thus,  when  these  viscera 
are  distended,  the  reflections  of  the  parietal  peri- 
toneum, being  attached  by  an  extremely  lax  layer 
of  subserous  tissue,  readily  allow  the  viscera  to 
expand  and  mount  up  from  the  pelvis.  When 
their  contents  are  being  expelled,  the  visceral  mus- 
culature requires  a  fixed  point  from  which  to  act. 
The  musculature  of  the  bladder  is  fixed  to  the 
back  of  the  pubis  and  triangular  ligament  by 
the  pubo-prostatic  ligament  and  capsule  of  the 
prostate;  it  is  also  attached  to  the  anterior 
parts  of  the  arcuate  ligajnents  of  the  levator 
ani  by  the  lateral  true  vesical  ligaments.  The 
vagina,  which  is  also  attached  to  the  arcuate  and 
triangular  ligaments,  affords  an  indirect  attach- 
ment of  the  uterus  to  the  pelvis  during  parturi- 
tion. The  anal  canal  is  fixed  in  the  posterior 
part  of  the  aperture  of  the  pelvic  floor.  The 
rectum  becomes  continuous  with  the  anal  canal ; 
anterior  bands  of  its  longitudinal  muscular  coat 
end  in  the  perineal  body.^  The  rectum  is  further 
fixed  by  its  sheath  becoming  continuous  with  the 
upper  layer  of  visceral  fascia  on  the  levator  ani, 
and  to  the  sacrum  and  coccyx.  The  visceral  fascia, 
which  covers  the  upper  or  pelvic  surface  of  the 
levatores  ani  and  thus  forms  part  of  their  sheath, 


474  ABDOMEN  AND  PELVIS 

and  the  stout  perivascular  sheaths  (named  sus- 
pensory ligaments),  help  to  support  the  pelvic 
viscera  in  the  following  manner  :  Above,  they 
are  attached  to  the  lateral  pelvic  wall  by  the 
fibrous  ligament  of  the  levator  ani;  below,  they 
blend  with  the  sheaths  of  the  prostate,  vagina, 
and  rectum.  When  the  viscera  are  in  their  normal 
position  and  the  levatores  ani  are  in  action,  these 
ligamentous  supports  are  slack;  it  is  only  when 
the  muscular  supports  of  the  pelvic  diaphragm 
are  relaxed  or  damaged  and  the  viscera  are  dis- 
placed that  these  ligamentous  supports  come  into 
action.  In  violent  movements  of  the  pelvic  viscera 
their  nerves  and  vessels  would  be  subjected  to 
strain  were  they  not  protected  by  strong  sheaths. 
As  at  the  shoulder-joint  the  muscles  retain  the 
bones  in  their  normal  position;  the  ligaments  act 
only  when  the  limit  of  muscle  action  is  exceeded. 
Siibserous  tissue  of  the  pelvis.— The  loose 
subserous  tissue  which  attaches  the  peritoneum 
to  the  pelvic  fascia  is  often  the  seat  of  in- 
flammatory processes,  especially  in  the  female. 
Between  the  broad  ligaments,  round  the  neck  of 
the  uterus  and  by  the  sides  of  the  vagina  it  is 
particularly  abundant,  and  forms  the  perimetric 
and  parametric  tissue.  It  allows  a  free  mobility 
to  the  vagina  and  uterus.  Inflammatory  processes 
and  abscesses  may  spread  rapidly  up  the  sides  of 
the  pelvis  and  into  the  iliac  fossae,  through  the 
subserous  stratum  of  connective  tissue.  In  this 
stratum,  too,  lie  the  ureter  and  the  iliac  vessels, 
surrounded  by  their  fibrous  sheaths.  In  this 
layer  are  also  the  nbro-muscular  bands  which 
form  the  utero-sacral  and  round  ligaments.  The 
utero-sacral  ligaments  encircle  the  pouch  of 
Douglas  and  bind  the  upper  part  of  the  vagina 
to  the  loose  tissue  of  the  sacrum.  The  fold  of 
peritoneum  at  the  bottom  of  the  recto-vesical  or 
recto-vaginal  pouch  is  fixed  to  the  ^ sheath  of  the 
prostate  or  vagina  and  to  the  perineal  body  by 
a  septum  of  fibrous  tissue  which  separates  the 
rectum  from  the  structures  anterior  to  it. 


CHAPTER   XXI 
THE     PERINEUM 

Male  perineum  (Fig.  105).— This  is  a,  lozenge: 
shaped  space  bounded  by  the  symphysis,  the  rami 
of  the  pubes  and  the  ischia,  the  ischial  tuber- 
osities,  the  great  sacro-sciatic  ligaments,  the 
edges  of  the  two  great  gluteal  muscles,  and  the 
coccyx.  A  transverse  line  drawn  across  the  space 
between  the  anterior  extremities  of'  the  tubera 
ischiorum,  and  just  in  front  of  the  anus,  divides 
the  perineum  into  two  parts.  The  anterior  part 
forms  nearly  an  equilateral  triangle,  measuring 
about  3j  inches  on  all  sides;  it  is  called  the 
urethral  triangle.  The  posterior  part  is  also 
somewhat  triangular,  contains  the  rectum  and 
ischio-rectal  fossae,  and  is  called  the  anal  triangle. 
The  bony  framework  of  the  perineum  can  be 
felt  more  or  less  distinctly  all  round,  and  in  thin 
subjects  the  great  sacro-sciatic  ligaments  can  be 
made  put  beneath  the  great  gluteal  muscle.  The 
anus  is  in  the  middle  line  between  the  ischial 
tuberosities,  its  centre  being  about  1^  inches  from 
the  tip  of  the  coccyx.  The  raphe,  a  lineal 
ridge  in  the  skin,  can  be  followed  from  the  anus 
along  the  middle  line  of  the  perineum,  scrotum, 
and  penis.  No  vessels  cross  this  line,  and,  there- 
fore^ in  making  incisions  into  the  perineum  the 
line  is  always  chosen  when  possible.  In  the  middle 
line,  midway  between  the  centre  of  the  anus  and 
the  spot  where  the  scrotum  joins  the  perineum,  is 
the  central  point  of  the  perineum.  The  two  trans- 
verse perineal  muscles,  the  bulbo-cavernosus  and 
the  sphincter  ani,  meet  at  this  point,  which  also 
corresponds  to  the  centre  of  the  inferior  edge  of 
475 


476 


ABDOMEN  AND  PELVIS 


[CHAP. 


the  triangular  ligament.  The  bulb  is  just  in 
front  of  it,  as  is  also  the  artery  to  the  bulb,  and 
in  lithotomy,  therefore,  the  incision  should  never 
commence  in  front  of  this  spot. 


Fig.   105. — The  male  perineum.     (After  Riidinger.) 

a,  Gluteus  maximus ;  6,  semi-tendinosus  and  biceps  ;  c,  adductor 
magnus  ;  d,  gracilis  ;  <?,  pyriformis  ;/,  obturator  internus  ;  g  quad- 
ratus  femoris  ;  h,  levator  ani  ;  /,  external  sphincter  ;  /,  bulbo- 
cavernosus  ;  k,  ischio-cavernosus  ;  Z,  trans  versus  perinei ;  1  sciatic 
nerve  ;  2,  inferior  haemorrhoidal  vessels  and  nerve  ;  3,  superficial 
perinea!  vessels  and  nerves;  4,  pudic  (internal  pudenda!)  nerve 
(cut)  and  pudic  artery  ;  5,  perineal  branch  of  posterior  cutaneous 
of  thigh. 

The  perineal  space  is  separated  from  the  pelvic 
cavity  by  the  levator  ani  muscles  and  the  fascial 


xxi]  ISCHIO-RECTAL  FOSSA  477 

structures  connected  with  them.  The  depth  of  the 
perineum  means  the  distance  between  the  skin  and 
the  pelvic  floor.  This  depth  depends,  to  a  great 
extent,  upon  the  amount  of  fat  under  the  integu- 
ment. It  varies  considerably  in  different  parts, 
measuring  from  2  to  3  inches  in  the  hinder  and 
outer  parts  of  the  perineum,  and  less  than  1  inch 
in  the  anterior  parts  of  the  space. 

The  ischio-rectal  fossa  is  of  pyramidal 
shape,  its  apex  being  at  the  lower  border  of  the 
levator  ani  (see  Fig.  106),  and  its  base  being 
forjned  by  the  skin  between  the  anus  and  the 
ischial  tuberosity.  The  fossa  is  shut  in  at  its  apex 
by  the  fusion  of  the  fibrous  layers  covering  its 
outer  and  inner  wall.  It  becomes  shallower  as 
it  passes  forwards,  and  ceases  opposite  the  base 
of  the  triangular  ligament.  It  measures  about 
2  inches  from  before  back,  1  inch  from  side  to 
side,  and  is  between  2  and  3  inches  in  depth.  Its 
boundaries  are  :  on  the  outer  side,  the  obturator 
internus  muscle,  covered  by  its  fascia  and  the 
fibrous  sheath  of  the  internal  pudic  vessels  and 
nerves  (Fig.  106);  on  the  inner  side,  the  levator 
ani,  covered  by  the  anal  fascia;  in  front,  the  base 
of  the  triangular  ligament  and  the  transversus 
perinei  muscle ;  and  behind,  the  gluteus  maximus, 
great  sacro-sciatic  ligament,  and  coccygeus.  The 
pudic  vessels  and  nerves  (internal  pudendal)  are 
placed  about  1|  inches  above  the  lower  border  of 
the  tuber  ischii.  The  fossa  is  occupied  by  a  mass 
of  fat  which  affords  to  the  anal  canal  the  support 
of  an  elastic  cushion.  This  fatty  tissue  is  badly 
supplied  with  blood,  and  this  fact,  in  addition 
to  the  dependent  situation  of  the  part,  and  its 
exposure  when  the  patient  sits  upon  damp,  cold 
seats,  etc.,  leads  to  abscess  being  very  frequent 
in  the  space  (ischio= rectal  abscess).  These  ab- 
scesses are  hemmed  in  on  all  sides,  soon  fill  the 
fossa,  and  then  tend  to  discharge  themselves  in 
the  two  directions  where  the  resistance  is  least, 
viz.  through  the  skin  and  through  the  wall  of  the 
anal  canal.  When  this  double  discharge  of  the 


478 


ABDOMEN  AND  PELVIS 


[CHAP. 


abscess  has  taken  place,  a  complete  fistula  in 
ano  is  established.  It  is  well  to  note  that  in 
fistulse  in  ano  the  opening  into  the  anal  canal  is 
nearly  always  within  -|  an  ^inch  of  the  anus.  An 
opening  into  the  bowel  high  up  is  resisted  by 
the  union  of  the  fibrous  covering  of  its  outer 
and  inner  wall  (Fig.  106). 

Crossing  the  space  obliquely  from  its  hinder 
part  to  the  anus  are  the  inferior  hsemorrhoidal 
vessels  and  nerves  (Fig.  105) ;  crossing  the  an- 


LONQ.  COAT     OBT.   INT.     ISCHIUM 
CIRC.  COAT.  .    nJ    .1     o       .    ,• 


PUDIC  VESSELS 


SEMITENDINOSUS 


ISCHIO-RECTAL  FOSSA 
LEVATOR  AMI 
GLUT.   MEDIUS 


WHITE  LINE 


Fig.  106. — Section  of  the  anal  canal  and  of  the  ischio- 
rectal  space.  (Modified  from  figures  b>/  Prof.  Elliot  Smith 
and  Sir  Charles  Ball.) 

terior  and  outer  corner  of  the  fossa  are  the 
perineal  vessels  and  nerves,  and  about  the  pos- 
terior border  of  the  space  are  the  fourth  sacral 
nerve  and  some  branches  of  the  small  sciatic 
nerve  (posterior  femoral  cutaneous).  It  will  be 
readily  understood,  therefore,  that  ischio-rectal 
abscesses  are  associated  usually  with  extreme 
suffering  until  they  are  relieved.  The  severe  pain 
is  probably  due  to  the  rich  nerve  supply  of  the 
skin  and  mucous  membrane  of  the  anus,  and  also 
to  the  stretching  of  the  external  hsemorrhoidal 


xxi]  URETHRAL  TRIANGLE  479 

nerve  by  the  abscess  as  it  progresses  towards  the 
surface.  In  opening  an  abscess  in  the  fossa  the 
main  structures  to  avoid  are  the  rectum,  the  pudic 
and  inferior  hsemorrhoidal  vessels. 

Anus.     (See  p.   518.) 

Urethra!  triangle.  —  The  skin  of  the  peri- 
neum between  the  anus  and  the  scrotum  is  thin, 
and  shows  very  readily  any  extravasations  of 
blood  that  may  form  beneath  it.  The  superficial 
fascia  is  divided  into  two  layers,  of  which  the 
more  superficial  is  quite  unimportant,  and  con- 
tains what  little  subcutaneous  fat  exists  in  this 
part. 

The  deep  layer,  known  as  the  perineal  fascia 
(fascia  of  Colles),  is  attached  on  either  side  to  the 
rami  of  the  pubes  and  ischium,  and  behind  to 
the  base  of  the  triangular  ligament.  In  front  it 
becomes  continuous  with  the  dartos  coat  of  the 
scrotum.  This  fascia,  therefore,  by  its  attach- 
ments forms  with  the  triangular  ligament  a  well- 
isolated  aponeurotic  space,  containing  the  bulb 
with  all  that  part  of  the  spongy  (cavernous) 
urethra  between  the  triangular  ligament  and  the 
attachment  of  the  scrotum,  the  penile  muscles,  the 
transverse  perineal  muscles,  vessels,  and  nerves, 
and  the  perineal  vessels  and  nerves.  When  extra- 
vasation of  urine  follows  upon  a  rupture  of  the 
part  of  the  urethra  above  named,  the  course  of 
the  escaping  fluid  is  directed  by  the  attachments 
of  this  pocket-shaped  fascia.  The  urine  fills  the 
pocket.  It  is  unable  to,  gain  the  ischio-rectal  fossa 
on  account  of  the  attachment  of  the  fascia  to  the 
triangular  ligament.  The  lateral  attachments  of 
this  membrane  prevent  the  urine  from  passing 
into  the  thighs.  It  is  therefore  guided  into  the 
scrotum,  and  there  finds  itself  beneath  the  dartos 
tunic.  It  distends  the  scrotal  tissues,  and  then 
mounts  up  on  to  the  abdomen  through  the  gap 
left  between  the  symphysis  pubis  and  pubic  spine. 
It  must  be  remembered  that  the  perineal  fascia, 
the  dartos  coat,  and  the  deeper  layer  of  the 
superficial  fascia  of  the  abdomen  are  .continuous, 


480  ABDOMEN  AND  PELVIS  [CHAP. 

and  merely  represent  different  parts  of  the  same 
structure.  Pus  or  blood  within  this  aponeurotic 
space  would  follow  the  same  course  if  the  effusion 
were  extensive  enough.  The  pain  occasioned  by 
such  effusion  can  be  understood  when  it  is  noted 
that  the  three  chief  sensory  nerves  of  this  region 
(the  two  superficial  perineal  from  the  pudic,  and 
the  perineal  branch  of  the  posterior  femoral 
cutaneous)  are  included  within  the  space  (Fig. 
105). 

The  triangular  ligament  has  a  depth  of 
about  1^  inches  in  the  middle  line,  and  is  formed 
of  two  layers,  of  which  the  posterior  is  thin, 
ill  defined,  and  formed  by  the  sheath  on  the 
lower  surface  of  the  pubic  fibres  of  the  levator 
ani.  The  membranous  urethra,  surrounded  by  the 
sphincter  (constrictor)  urethrae,  lies  between  the 
two  layers,  and  runs  about  1  inch  below  the  sym- 
physis,  and  about  f  of  an  inch  above  the  central 
point  of  the  perineum  (Fig.  107).  The  artery 
to  the  bulb  passes  inwards  between  the  two 
layers  about  J  an  inch  above  the  base  of  the 
ligament  and  1|  inches  in  front  of  the  anus. 
The  terminal  part  of  the  pudic  artery  pierces  the 
anterior  layer  of  the  ligament  about  ^  an  inch 
below  the  symphysis.  The  dorsal  vein  of  the 
penis  enters  the  pelvis  between  the  subpubic  liga- 
ment and  the  apical  part  (transverse  part)  of 
the  triangular  ligament;  the  dorsal  nerve  accom- 
panies it  (Elliot  Smith).  In  uncomplicated  rup- 
ture of  the  membranous  urethra  the  urine  extra- 
vasated  would  be  limited  to  the  space  between  the 
layers  of  the  ligament  until  subsequent  suppura- 
tion had  made  a  way  for  it  to  escape.  When 
extravasation  occurs  behind  the  triangular  liga- 
ment, the  effusion  may  collect  in  the  retropubio, 
space  if  the  capsule  of  the  prostate  is  ruptured 
(Deanesley),  or  it  may  pass  backwards  by  the 
side.^of  the  rectum  into  the  cellular  tissue  of  the 
pelvis. 

On  thp^  deep  or  pelvic  aspect  of  the  triangular 
ligament  is  the  prostate,  surrounded  by  its  capsule 


XXI] 


TRIANGULAR  LIGAMENT 


481 


and  the  prqstatic  venous  plexus  (Figs.  107  and 
108).  In  dissecting  down  from  the  surface  to 
the  prostate,  we  meet,  as  Cunningham  has  well 


Fig.   107.— Vertical    antero-posterior  section  of   the   male 

pelvis.      (Braune.) 
Q 


482  ABDOMEN  AND  PELVIS  [CHAP. 

pointed  out,  alternate  strata  of  fascial  and  inus- 
*eular  tissue,  forming  seven  layers  in  all,  viz.  : 
(1)  superficial  fascia;  (2)  superficial  perineal 
muscles;  (3)  triangular  ligament  (anterior  layer) ; 
(4)  sphincter  urethrse  muscle;  (5)  triangular  liga- 
ment (posterior  layer);  (6)  levator  ani  muscle; 
(7)  sheath  of  prostate. 

Stone  in  the  bladder. — Stones  in  the  bladder, 
which  were  formerly  removed  by  a  perineal  in- 
cision, are  now  commonly  crushed  and  washed  out 
through  the  urethra  by  the  operation  of  litho- 
lapaxy.  This  operation  is  carried  out  readily 
even  in  male  children.  If  the  stones  are  too 
large  for  crushing,  the  suprapubic  operation  is 
performed  to  give  sufficient  room  for  extraction. 

In  operations  for  the  removal  of  vesical  calculi 
in  children  it  must  be  kept  in  mind  that  in  them 
the  pelvis  is  relatively  narrower  than  in  the 
adult,  the  bladder  is  more  an  abdominal  than 
a  pelvic  organ,  and  the  neck  of  the  bladder, 
therefore,  is  high  up.  The  viscus,  moreover,  is 
very  movable,  and  has  less  substantial  attach- 
ments than  has  the  adult's  bladder.  In  children 
the  prostate  is  slightly  developed,  and  thus  more 
of  the  actual  neck  of  the  bladder  is  exposed.  In 
children  also  the  peritoneum  descends  lower  on 
the  posterior  surface  of  the  bladder  than  in  the 
adult  (see  p.  491). 

In  perineal  Hthotomy,  and  in  other  operations 
for  reaching  the  neck  of  the  bladder  by  this  route, 
it  should  be  remembered  that  the  bladder  lies  at 
a  depth  of  from  2j  to  3  inches  from  the  surface 
when  the  body  is  in  the  lithotomy  position.  If 
the  bladder  is  empty  and  the  rectum  full,  the 
prostate,  trigone,  and  reflection  of  peritoneum  are 
carried  upwards  and  forwards;  if  the  bladder 
is  full  and  the  rectum  empty,  the  movement  is  in 
an  opposite  direction.  In  fat  people  the  bladder 
and  peritoneum  are  carried  away  from  the  peri- 
neum ;  in  lean  people  the  opposite  is  the  case. 

Suprapubic  lithotomy.  —  This  operation  has 
been  revived  of  late  years,  and,  in  cases  in  which 


xxi]  THE   BLADDER  483 

Htholapaxy  is  contraindicatcd,  has  supplanted 
perinea!  operations.  In  order  to  bring  the  summit1 
of  the  bladder  well  above  the  symphysis,  both 
bladder  and  rectum  may  be  dilated.  Into  the 
former  viscus,  tepid  water  or  boric  lotion  is  in- 
jected. It  is  found  that  in  the  adult  8  to  10  oz. 
is  sufficient  to  ensure  the  desired  distension.  In 
the  case  of  a  male  child  aged  5,  the  injection 
of  3  oz.  of  water  into  the  bladder  caused  the 
reflection  of  peritoneum  to  mount  to  more  than 
1  inch  above  the  symphysis.  An  incision,  some 
3  inches  in  length,  is  made  immediately  above  the 
symphysis  in  the  median  line.  The  bladder  is 
exposed  below  the  peritoneum,  is  drawn  forwards 
by  a  hook,  and  opened.  * 

The  bladder.— During  micturition  the  mus- 
cular coats  of  the  bladder  contract  until  the 
organ  becomes  a  firmly  contracted  cone-shaped 
body,  its  lining  membrane  being  thrown  into  folds 
and  its  lumen  completely  obliterated  by  the  end 
of  the  act.  All  parts  contract,  the  trigone  as 
well  as  the  dome.  When  the  act  is  finished  the 
bladder  relaxes  and  becomes  triangular  in  outline, 
flattened  against  the  anterior  half  of  the  pelvic 
floor  or  diaphragm,  the  apical  part  resting 
against  the  posterior  aspect  of  the  symphysis. 
Then  it  begins  to  fill ;  at  very  short  intervals  of 
time,  tiny  jets  of  urine  are  forced  in  at  the  two 
ureteric  orifices,  situated  at  the  lateral  angles  of 
the  trigone,  by  the  peristaltic  waves  which  sweep 
slowly  down  the  ureters.  The  ureters  act  as 
hydraulic  pumps  in  the  filling  of  the  bladder ;  the 
ureteric  orifices  are  valvular,  and  the  vesical 
musculature  at  their  orifices  acts  so  as  to  produce 
a  sphincteric  effect,  thus  preventing  reflux.  As 
the  bladder  fills,  its  muscular  coats  pass  into  a 
state  of  passive  contraction  or  tonus;  as  in  all 
involuntary  muscle,  the  tone  of  the  bladder  is 
rhythmical,  waxing  and  waning.  The  muscular 
coats  yield  reflexly  and  adapt  themselves  to  the 
increasing  content  until  a  certain  point  is 
reached — a  point  which  gives  the-  sensation  of 


484:  ABDOMEN  AND  PELVIS  [CHAP. 

fullness  and  discomfort.  The  escape  of  urine  is 
prevented  (1)  by  the  involuntary  or  reflex-acting 
vesical  sphincter  (internal  sphincter),  which  sur- 
rounds the  neck  of  the  bladder  and  commence- 
ment of  the  urethra  (Fig.  108,  A,  A);  (2)  by  the 
voluntary  urethral  sphincter,  placed  between  the 
layers  of  the  triangular  ligament  (Fig.  108,  E,  E). 
The  act  of  micturition  is  initiated  by  a  voluntary 
compression  of  the  bladder  (by  the  abdominal  and 
pelvic  musculature)  which  is  sufficient  to  over- 
come the  vesical  sphincter  and  force  urine  into 
the  upper  part  of  the  urethra.  Urine  in  the 
urethra  produces  a  reflex  inhibition  of  the  sphinc- 
ters, and  at  the  same  time  stimulates  the  con- 
traction of  the  expelling  vesical  musculature. 
Thus  in  life  the  shape  of  the  bladder  and  its 
relationships  are  constantly  changing.  At  death 
we  may  find  the  bladder  in  every  stage  of  con- 
traction (systole)  or  of  relaxation  (diastole). 

When  moderately  distended  with  an  opaque 
solution  and  examined  by  the  aid  of  X-rays,  the 
bladder  is  seen  to  be  conical  in  form,  with  its 
apex  behind  the  symphysis  and  its  base  or  upper 
surface  indented  by  the  pressure  of  the  abdominal 
viscera  (Fig.  103,  p.  457).  As  distension  of  the 
bladder  increases,  the  summit  of  the  viscus  is 
brought  more  and  more  in  contact  with  the  an- 
terior abdominal  wall,  the  organ  becoming  also 
more  convex  on  its  posterior  than  on  its  anterior 
surface.  This  tendency  for  the  summit  of  the 
distended  bladder  to  press  itself  against  the 
anterior  parietes  is  of  good  service  in  tapping 
the  organ  above  the  pubes,  and  also  in  supra- 
pubic  lithotomy.  When  greatly  distended  it  may 
reach  the  umbilicus,  and  may  even  touch  the 
diaphragm.  The  usual  capacity  _  of  the  organ  is 
about  one  pint,  but  when  quite  full  it  may 
hold  some  quarts.  When  both  bladder  and  rec- 
tum are  quite  empty  the  apex  of  the  bladder  and 
the  prevesical  reflection  of -the  peritoneum  are  a 
little  below  the  upper  margin  of  the  symphysis 
pubis.  As  the  distended  bladder  ascends  above 


xxi]         DISTENSION   OF  THE   BLADDER         485 

the  pubes  it  dissects  the  serous  membrane  from 
the  parietes,  and  the  layer  so  lifted  off  forms 
a  cul-de-sac  or  fold  of  peritoneum  between  the 
upper  part  of  the  anterior  surface  of  the  bladder 
and  the  parietes.  When  the  apex  of  the  bladder  is 
2  inches  above  the  pubes  the  peritoneal  reflection 
is  probably  not  more  than  f  of  an  inch  above 
the  same  point  of  bone.  When  the  apex  of  the 
bladder  is  midway  between  the  umbilicus  and 
the  pubes  there  may  be  2  inches  (vertical)  of  the 
anterior  abdominal  wall  in  the  middle  line  and 
immediately  above  the  symphysis  devoid  of  peri- 
toneal lining.  Thus  it  happens  that  the  distended 
viscus  may  be  tapped  above  the  pubes  without 
the  peritoneum  being  wounded,  but  this  is  not 
always  the  case  (R.  Thompson).  As  the  bladder 
becomes  distended,  not  only  does  it  rise  into  the 
abdomen,  but  it  extends  also  towards  the  peri- 
neum, diminishing  the  length  of  the  prostatic  and 
membranous  urethra. 

Between  the  anterior  surface  of  the  bladder 
and  the  symphysis,  and  shut  in  by  the  peritoneum 
above,  is  the  retropubic  or  prevesical  space,  con- 
taining lax  connective  tissue  (Fig.  108).  The  loose- 
ness of  this  connective  tissue  permits  the  bladder 
readily  to  ascend  as  it  fills.  In  injuries  to  the 
pelvis  and  to  the  front  of  the  bladder  a  diffuse 
inflammation  may  be  set  up  in  this  tissue  and 
assume  serious  proportions.  Extension  of  a  retro- 
pubic  abscess  into  the  perineum  is  limited  by  the 
fascial  reflections  formed  by  the  pubo-prostatic 
and  lateral  vesical  ligaments. 

The  bladder,  although  fairly  fixed,  has  been 
found  in  inguinal,  femoral,  and  vaginal  hernise. 
In  the  erect  position  its  neck  (in  the  male)  lies 
on  a  horizontal  line  drawn  from  before  backwards 
through  a  point  a  little  below  the  middle  of  the 
symphysis,  and  is  placed  about  1|  inches  (3  cm.) 
behind  that  articulation,  but  its  position  varies 
with  the  fullness  of  the  bladder  and  the  state  of 
the  rectum. 

Relations  of  the  bladder  to  the  peritoneum.— The 


486  ABDOMEN  AND  PELVIS  [CHAP. 

pubic  surface  is  entirely  devoid  of  peritoneum, 
while  the  superior  surface  is  entirely  covered  by  that 
membrane.  At  the  sides  there  is  no  peritoneum 
in  front  of,  or  below,  the  obliterated  hypogastric 
arteries.  On  the  posterior  aspect  of  the  bladder 
the  serous  membrane  extends  down  as  far  as  a 
transverse  line  uniting  the  upper  parts  of  the 
two  seminal  vesicles,  so  that  the  upper  ends  of 
the  vesicles  are  covered  by  peritoneum.  This 
recto-vesical  pouch  of  peritoneum  in  the  adult  ex- 
tends to  within  about  3  inches  of  the  anus,  and 
does  not  reach  below  a  line  1  inch  above  the  base 
of  the  prostate.  Harrison  Cripps  gives  the  dis- 
tance of  the  pouch  from  the  anus  as  2^  inches 
when  the  bladder  and  rectum  are  both  empty, 
and  as  3^  inches  when  those  viscera  are  distended. 
(See  Bladder  in  the  Child,  p.  490.) 

Puncture  of  the  bladder  per  rectum The 

base  of  the  bladder  is  applied  to  the  lower  part 
of  the  rectum,  but  they  are  separated  by  a 
thin  fibrous  septum — the  recto-vesical.  The  area 
in  contact  with  the  rectum  is  triangular  in 
shape,  the  apex  being  formed  by  the  prostate, 
the  sides  by  the  diverging  seminal  vesicles,  and 
the  base  by  the  recto-vesical  fold  of  peritoneum. 
This  triangle  is  equilateral,  and  in  the  dissected 
specimen  measures  about  1^  inches  on  all  sides. 
It  corresponds  to  the  trigone  on  the  inner  surface 
of  the  viscus.  It  is  through  this  triangle,  and 
as  near  as  possible  to  the  prostate,  that  the  blad- 
der is  tapped  when  the  operation  is  performed 
per  rectum.  The  recto-vesical  fold  of  peritoneum 
is  raised,  and  is  carried  still  farther  from  the 
anus  when  the  organ  is  distended. 

Rupture  of  bladder.— The  bladder  may  be 
ruptured  by  violence  applied  to  the  anterior 
abdominal  wall  apart  from  pelvic  fracture  or 
external  evidence  of  injury.  Such  a  rupture  can, 
however,  hardly  happen  to  the  empty  bladder; 
it  must  be  full  or  distended  at  the  time  of  the  acci- 
dent. f  It  is  very  rare  for  the  rupture  to  be  on  the 
anterior  surface  only.  As  a  rule,  the  tear  in- 


xxi]  RUPTURE   OF  THE   BLADDER  487 

yolves  the  superior  or  abdominal  surface,  and 
implicates  the  peritoneum.  The  injury,  therefore, 
is  very  fatal  (5  recoveries  out  of  78  cases). 
In  some  cases  of  vesical  rupture  the.  surgeon 
has  opened  the  abdomen  and  has  stitched  up 
the  rent  in  the  viscus  with  perfect  success.  The 
bladder  may  be  torn  by  fragments  of  bone  in 
fractures  of  the  pelvis,  or  by  violence  applied 
through  the  rectum  or  vagina.  A  case,  for  ex- 
ample, is  reported  (Holmes's  "  System  of  Sur- 
gery ")  of  a  man  who  fell  upon  a  pointed  stake 
fixed  in  the  earth.  The  stake  passed  through  the 
anus,  pierced  the  rectum,  and  entered  the  blad- 
der near  the  prostate.  The  patient  recovered,  the 
wound  having  been  made  in  the  triangular  area 
on  the  fundus  of  the  bladder  alluded  to  above, 
and  therefore  outside  the  peritoneum.  The  viscus 
may  be  ruptured  by  an  accumulation  of  urine,  as 
seen  in  cases  of  congenital  closure  of  the  urethra 
in  some  infants.  In  the  museum  of  the  Royal 
College  of  Surgeons  is  a  preparation  of  "  the 
bladder  of  a  woman  which  burst  near  the  entrance 
of  the  ureter  in  consequence  of  neglected  reten- 
tion of  urine."  In  neglected  cases  of  stricture  in 
the  male  the  urethra  gives  way  rather  than  the 
bladder,  and  an  extravasation  of  urine  into 
the  perineum  follows.  A  small  puncture  of  the 
bladder,  as,  for  example,  that  made  by  a  fine 
trocar,  is  at  once  closed  by  the  muscular  con- 
traction of  its  wall. 

The  mucous  membrane  of  the  bladder  is 
very  lax,  to  allow  of  its  accommodating  itself  to 
the  varying  changes  in  the  size  of  the  viscus. 
Over  the  trigone,  however,  it  is  closely  adherent, 
and  were  it  not  so  the  loose  mucous  membrane 
would  be  constantly  so  prolapsed  into  the  urethral 
orifice  during  micturition  as  to  block  up  the  neck 
of  the  bladder.  When  examined  by  the  cystoscope, 
the  mucous  membrane  is  seen  to  be  red  and  con- 
gested when  the  bladder  is  empty,  pale  and 
anaemic  when  the  bladder  is  full  (Newman).  The 
trigone  is  bounded  by  three  orifices,  for  the  urethra 


488  ABDOMEN  AND  PELVIS  [CHAP. 

and  the  two  ureters,  and  forms  an  equilateral 
triangle,  measuring  about  li  inches  on  all  sides. 
It  is  here  that  the  effects  of  cystitis  are  most  evi- 
dent, and  the  unyielding  character  of  the  mucous 
membrane  over  the  trigone  serves  in  part  to  ex- 
plain the  severe  symptoms  that  follow  acute  in- 
flammation of  that  structure.  Since  the  orifice 
of  the  urethra  forms  the  lowest  part  of  the  bladder 
in  the  erect  posture,  it  follows  that  calculi  gravi- 
tate towards  the  trigone,  and  are  very  apt  to 
irritate  that  part  of  the  interior.  The  same  re- 
mark applies  to  foreign  bodies  in  the  viscus.  The 
mucous  membrane  about  the  trigone  and  neck  is 
very  sensitive,  whereas  the  interior  of  the  re- 
mainder of  the  bladder  appears  to  be  singularly 
defective  in  common  sensation.  This  can  be  well 
noted  in  using  sounds  and  catheters. 

The  sensory  nerves  for  the  bladder  are  de- 
rived mainly  from  two  parts  of  the  spinal  cord, 
namely,  the  twelfth  dorsal  and  first  lumbar  seg- 
ments, and  the  second,  third,  and  fourth  sacral 
segments.  From  the  first  source  (through  the 
hypogastric  plexus)  come  the  sensory  nerves  to 
the  upper  part  of  the  bladder,  and  .the  motor 
nerves  which  stimulate  the  internal  sphincter  to 
contract  and  inhibit  the  expelling  musculature; 
and  from  the  second  source  (through  the  nervi 
erigentes)  the  motor  fibres  which  stimulate  the 
expelling  musculature  and  inhibit  the  sphincter. 
The  trigone,  having  the  same  nerve  supply  as  the 
penis  and  scrotum,  gives  rise,  when  injured,  to 
pains  which  are  referred  along  the  perineal 
nerves.  The  co-ordination  of  the  various  struc- 
tures concerned  in  the  act  of  micturition  ie  a 
function  of  a  nerve  centre  (micturition  centre)  in 
the  lumbar  part  of  the  spinal  cord. 

In  the  muscular  coat  of  the  bladder  the  fibres 
are  collected  in  bundles  which  interlace  in  all 
directions.  When  the  viscus  becomes  hypertro- 
phied  these  bundles  are  rendered  very  distinct, 
and  produce  the  .appearance  known  as  "fascicu- 
lated bladder."  This  simply  means  that  the 


xxi]  THE   URETERS  489 

muscle  of  the  bladder,  having  been  unduly  exer- 
cised to  overcome  some  obstruction  to  the  escape 
of  urine,  increases  in  size,  as  do  other  much- 
exercised  muscles,  and  that  increase  serves  to 
demonstrate  the  arrangement  of  the  individual 
bundles.  From  distension  the  mucous  membrane 
becomes  bulged  out  between  the  unyielding  muscle 
bundles,  so  that  sacculi  are  formed,  and  the  ap- 
pearance known  as  "sacculated  bladder"  is  pro- 
duced. In  some  cases  the  parietes  yield  especially 
at  one  part,  and  one  large  saccule  is  produced. 
In  this  way  a  sacculus  may  be  formed  which  in 
time  may  become  almost  as  large  as  the  bladder 
itself,  and  give  rise  to  the  erroneous  description 
of  "  double  bladder,"  etc. 

The  ureters  run  for  f  of  an  inch  in  the  mus- 
cular wall  of  the  viscus,  and  their  oblique  course, 
together  with  the  action  of  the  neighbouring 
vesical  musculature,  prevents  the  regurgitation  of 
urine  from  the  bladder.  ^  No  circular  muscular 
fibres  surround  the  termination  of  the  ureter ; 
there  is  nothing  in  the  nature  of  a  sphincter  to 
safeguard  the  orifice  (T.  B.  C.  Benians).  On 
cystoscopic  examination  it  is  seen  that  once  or 
twice  a  minute  each  ureter  contracts  and  expels 
a  spurt  of  urine^  into  the  bladder ;  between  these 
spurts  the  ureteric  orifices  are  closed  by  the  intra- 
vesical  pressure.  If  the  ureter  becomes  shortened, 
as  is  the  case  if  it  is  the  seat  of  a  tubercular 
ulceration,  the  vesical  orifice  of  the  ureter  is 
drawn  outwards  (Fenwick).  The  mucous  mem- 
brane is  laxly  attached  and  may  be  prolapsed 
within  the  bladder  as  a  pedunculated  body.  In 
cases  of  retention  the  ureters  become  distended; 
but  this  is  due  rather  to  accumulation  of  urine 
within  them  than  to  its  reflux  from  the  bladder. 
In  cases  of  great  distension  of  the  bladder  the 
neck  of  the  viscus  is  opened  up  by  the  pressure 
from  within,  .and  the  patient  exhibits  the  feature 
of  overflow  of  urine.  A  band  of  muscle  passes 
from  the  sheath  of  the  ureter  towards  the  in- 
ternal urinary  meatus  along  each  side  of  the 
Q* 


490  ABDOMEN  AND  PELVIS  [CHAP. 

trigone  (Bell's  muscle),  while  another  (Mercier's 
bar)  unites  the  orifices  across  the  base.  These 
bands  maintain  the  ureteral  orifices  in  position 
when  the  bladder  is  full,  and  safeguard  their 
valvular  mechanism  (Wright  and  Benians).  In- 
fections spread  readily  from  the  bladder  to  the 
ureter  and  from  the  ureter  to  the  pelvis  of  the 
kidney;  the  valvular  orifice  of  the  ureter  offers 
no  hindrance  to  them. 

The  female  bladder  is  less  capacious  than 
that  of  the  male.  Its  neck  is  situated  a  trifle 
nearer  to  the  symphysis  than  it  is  in  the  male, 
and  lies  in  a  horizontal  line  continued  back  from 
the  lower  border  of  the  symphysis.  There  being 
no  prostate,  the  neck  of  the  bladder  is  very  dis- 
tensible, and  this  fact,  taken  in  connexion  with 
the  shortness  and  dilatability  of  the  urethra, 
allows  of  most  stones  being  extracted  by  forceps 
without  cutting.  By  simple  dilatation,  stones  of 
a  diameter  of  f  of  an  inch  have  been  removed. 
Through  the  dilated  urethra  the  orifices  of  the 
ureters  can  be  seen  and  examined.  The  intimate 
relation  of  the  bladder  to  the  vagina  allows  it  to 
be  examined  well  from  the  latter  passage,  and 
the  comparative  thinness  of  the  dividing  wall 
serves  to  explain  the  frequency  of  vesico-vaginal 
fistulse.  Strange  foreign  bodies  have  been  intro- 
duced into  the  female  bladder,  such  as  hair-pins, 
crochet-hooks,  sealing-wax,  penholders,  and  the 
like. 

The  orifice  of  the  ureter  is  3  cm.  from  the  cervix 
uteri,  and  4  cm.  from  the  vesical  opening  of  the 
urethra.  The  close  relation  of  the  ureter  to  the 
cervix  renders  it  liable  to  injury  in  supravaginal 
amputation  of  that  part,  and  in  certain  opera- 
tions on  the  uterus. 

The  bladder  in  the  child  is  egg-shaped,  and 
its  vertical  axis  is  relatively  much  greater  than 
in  the  adult.  The  larger  end  of  the  egg-shaped 
cavity  (the  base  or  fundus)  is  directed  downwards 
and  backwards.  The  base  is  developed  and  the 
pelvic  position  assumed  about  the  fourth  year 


xxi]  THE  PROSTATE  491 

(Birmingham).  The  viscus  is  situated  mainly  in 
the  abdomen,  the  pelvis  being  small  and  very 
shallow.  At  birth  the  orifice  of  the  urethra  is  on 
a  level  with  the  upper  edge  of  the  symphysis. 
Although  the  bladder  projects  so  freely  into  the 
abdomen,  its  pubic  wall  is  still  entirely  uncovered 
by  peritoneum.  On  the  posterior  wall  the  serous 
membrane  extends  lower  down  than  in  the  adult, 
reaching  the  level  of  the  urethral  orifice  at  the 
time  of  birth,  and  the  level  of  the  prostate  in 
young  male  children.  The  prostate  is  exceedingly 
small  in  children.  Thompson  states  that  at  the 
age  of  7  years  it  only  weighs  30  gr.,  whereas 
in  subjects  between  18  and  20  it  weighs  250  gr. 
The  bladder  wall  in  the  child  is  so  thin  that  in 
sounding  for  stone  it  is  said  that  a  "click" 
may  be  elicited  by  striking  the  pelvis  through 
the  parietes  of  the  viscus. 

The  prostate.  —The  prostate  is  situated  about 
|  of  an  inch  below  the  symphysis  pubis,  and  rests 
upon  the  rectum  above  the  anal  canal  (Fig.  107). 
It  is,  therefore,  placed  within  1^  to  2  inches  of 
the  anus,  and  can  be  readily  examined  from  the 
bowel.  The  prostate  is  made  up  of  two  lateral 
lobes  which  fuse  together  in  front  of  the  urethra 
by  a  pubic  commissure  (Fig.  108)  and  behind  by 
two  commissures,  one  above  the  common  ejacula- 
tory  ducts — the  median  commissure — and  one  be- 
low those  ducts — the  rectal  commissure  (see  Fig. 
108,  B,  D).  The  part  here  named  median  commis- 
sure was  formerly  known  as  the  median^  lobe — a 
name  which  is  apt  to  mislead,  for  it  is  not  a 
separate  lobe,  but,  as  already  explained,  merely 
a  fusion  of  the  two  lateral  lobes.  Each  gland 
is  made  up  of  numerous  branching  tubular  glands 
which  are  embedded  in  and  surrounded  by  non- 
striated  muscle  and  fibrous  tissue.  The  glands 
end  in  the  urethra — chiefly  in  the  prostatic 
sinuses — but  the  use  of  their  secretion  is  un- 
known. The  secretion  is  discharged  through  the 
long  and  very  narrow  ducts.  In  certain  forms 
of  prostatic  irritation,  little  white  opaque  threads, 


492 


ABDOMEN  AND  PELVIS 


[CHAP. 


very  much  like  short  pieces  of  cotton,  are  found 
in  the  urine,  and  are  actual  casts  of  the  prostatic 
ducts. 

Capsule  of  the  prostate. — Owing  to  the  suc- 
cess which  has  attended  enucleation  as  a  means 
of  treatment  for  enlarged  prostate,  much  dis- 
cussion has  recently  taken  place  concerning  its 
ensheathing  structures.  The  term  capsule  has 


Fig.    108. — 1,    Median   section    of    the    normal    prostate; 
2,  similar  section  of  enlarged  prostate. 

A,  A,  Sphincter  vesicse  ;  B,  median  commissure  ;  C,  common  ejacu- 
latory  duct ;  D,  rectal  commissure  ;  E,  E,  sphincter  urethree ; 
F,  recto-urethral  muscle  ;G,Cowper's  gland  ;  H.'bulbo-cavernosus  ; 
I,  internal  sphincter  of  anus  ;  J,  external  sphincter  of  anus  ; 
K,  symphysis  pubis  ;  L,  retropubic  space  ;  M,  pubo-prostatic  liga- 
ments and  sheath  of  prostate  ;  N,  dorsal  vein  of  penis  ;  O,  pubic 
commissure  ;  P,  corpus  cavernosum  ;  Q,  urethra :  R,  bulb. 

been  proposed  for  the  superficial  nbro-muscular 
stratum  of  the  gland,  while  the  term  sheath 
has  beon  applied  to  the  enveloping  fibrous  struc- 
ture ^  derived  from  the  pelvic  fascia.  In  enu- 
cleating the  gland  everything  within  the  sheath 
is  removed.  At  only  one  part  is  the  sheath  in- 
timately adherent  to  the  capsule,  and  that  is 
along  the  anterior  or  pubic  surface;  elsewhere 
it  is  free  of  it.  Since  the  base  of  the  prostate  is 


xxi]  PROSTATIO  ABSCESS  493 

applied  to  the  bladder  and  uncovered  by  the 
sheath,  while  elsewhere  it  is  enclosed,  it  follows 
that  the  sheath  is  most  easily  entered  and  the 
gland  enucleated  from  the  bladder  (Fig.  108,  B). 
The  apex  of  the  prostate  rests  on  the  sphincter 
urethrse;  its  sides  are  applied  to  the  pubo-rectal 
(pubo-coccygeal)  fibres  of  the  levator  ani ;  hence 
the  sheath  of  the  prostate  fuses  with  the  adjacent 
sheaths  of  these  two  muscles.  The  prostatic  plexus 
of  veins,  which  receives  the  vesical  veinsy  tribu- 
taries and  communications  of  the  dorsal  vein  of 
the  penis,  internal  pudic  (pudendal)  and  obtura- 
tor veins,  lies  in  the  fibrous  tissue  between  the 
prostate  and  levator  ani.  The  tissue  to  the  outer 
side  of  the  veins  is  counted  sheath ;  that  to  the 
inner,  capsule.  The  sheath  of  the  prostate  on  the 
posterior  or  rectal  aspect  is  formed  by  the  recto- 
vesical  septum. 

The  prostatic  abscess  usually  bursts  into 
the  urethra,  that  being  the  direction  in  which 
least  resistance  is  enc9untered.  If  it  does  not 
enter  the  urethra,  it  will  probably  open  into  the 
rectum,  there  being  only  the  recto-vesical  septum 
of  fascia  between  the  two  organs.  This  encase- 
ment of  the  gland  in  an  unyielding  membrane 
will  serve,  in  part,  to  explain  the  severe  pain 
felt  in  acute  prostatic  abscess.  In  acute  prostat- 
itis  pains  are  referred  over  the  tip  of  the  last 
rib  (tenth  dorsal  nerve),  over  the  posterior  iliac 
spine  (eleventh  dorsal  nerve),  or  even  to  the  soles 
of  the  feet  (third  sacral  nerve).  The  prostate 
derives  its  nerve  supply  from  the  lower  three 
dorsal  and  upper  three  sacral  segments;  hence 
the  widely  distributed  character  of  the  referred 
pains  (Head). 

Hypertrophy  of  the  prostate.  —  The  average 
measurements  of  the  normal  prostate  are  l£  inches 
across  at  its  widest  part,  and  l£  inches  from 
before  backwards,  or  from  apex  to  base.  After 
the  age  of  53  the  organ  is  very  apt  to  become 
hypertrophied ;  and,  according  to  Sir  Henry 
Thompson,  this  hypertrophy  may  bo  considered 


494  ABDOMEN  AND  PELVIS  [CHAP. 

to  exist  when  the  gland  measures  2  inches  from 
side   to  side,   or   when   it  weighs   1   oz.   or   more. 
The    usual    weight   of   the   prostate   is   f   oz.      If 
the  enlargement  mainly  affect  the  lateral  parts, 
it  will  be  understood  that  the  hypertrophy  may 
attain  considerable  dimensions  without  retention 
of  urine  being  produced.     On  the  other  hand,   a 
comparatively  trifling  enlargement  of  the  median 
commissure  (third  lobe)  may  almost  entirely  block 
the  orifice  of  the  urethra.     As  this  part  enlarges 
it  pushes   its  way  into  the  bladder   through  the 
urethral     orifice,     dilating    and    destroying    the 
sphincter   vesicae  and   forming   a   mechanical   ob- 
struction to  the  free  passage  of  urine  (Fig.  108,  2). 
If  the  affection  be  general,  the  prostatic  urethra  is 
lengthened,  and  if  one  lateral  lobe  be  more  en- 
larged than  the  other,  the  canal  deviates  to  one 
side.     When  the  enlargement  particularly  affects 
the    median    commissure,    the    prostatic    urethra, 
which  is  normally  almost  straight,   becomes  con- 
siderably curved,  the  curve  being  sometimes  very 
abrupt.     It    is   important    to  note    that  enlarge- 
ment of  the  median  commissure  alone  can  hardly 
be  made  out  by  rectal  examination.     The  project- 
ing middle  commissure,  when  viewed  from  the  in- 
terior of  the  bladder,  may  appear  as  a   distinct, 
well-rounded,   pedunculated  or  sessile  growth. 

In  the  operation  of  prostatectomy  this  pro- 
jecting and  most  troublesome  mass  is  removed 
through  a  suprapubic  incision.  Everything 
within  the  sheath  of  the  prostate — gland,  urethra, 
common  ejaculatory  ducts— is  enucleated  by  the 
surgeon's  finger  through  the  base  of  the  bladder ; 
the  sheath  then  encloses  a  space  which  at  first  is 
filled  with  blood  and  urine,  but  afterwards  con- 
tracts to  form  a  new  urethra.  In  spite  of  the 
destruction  of  the  prostatic  part  of  the  urethra, 
the  patient  soon  attains  control  of  the  act  of 
micturition.  The  sphincter  urethrse  is  undamaged. 
The  prostate  is  a  sexual  organ,  and  its  size  and 
development  depend  on  the  presence  and  activity 
of  the  testes.  In  early  life  castration  prevents 


xxi]  MALE   URETHRA  495 

its  development  or  causes  atrophy  if  already 
developed;  but  this  is  only  partially  true  when 
the  operation  is  performed  after  the  full  develop- 
ment of  sexual  life.  Removal  of  one  testicle 
causes  a  partial  atrophy,  but  section  of  the  vasa 
deferentia  has  usually  no  effect  (C.  Wallace).  The 
lymphatics  of  the  prostate,  which  are  numerous, 
pass  to  a  group  of  glands  on  the  wall  of  the 
pelvis,  between  the  external  and  internal  iliac 
arteries. 

The  male  urethra  is  about  8j  inches  in 
length  (21  cm.),  l£  inches  being  devoted  to  the 
prostatic  urethra,  |  of  an  inch  to  the  mem- 
branous, and  63  inches  to  the  penile  or  spongy 
(cavernous)  portion.  Between  the  ages  of  4  and  6 
years  its  length  is  8  to  9  cm.,  and  between  10  and 
13  years  10  to  It  cm.  The  canal  may  be  divided 
into  a  pelvic  and  relatively  fixed  and  a  perineal, 
penile  or  movable  part.  The  pelvic  part  extends 
from  the  neck  of  the  bladder  to  the  anterior  layer 
of  the  triangular  ligament.  The  sphincter  urethrse 
makes  a  functional  demarcation  of  the  two  parts. 
This  pelvic  part  describes  an  even  curve,  fairly 
represented  by  a  line  parallel  with  the  axis  of 
the  outlet  of  the  pelvis.  The  "  short  curve"  of 
a  metallic  catheter  is  designed  to  accommodate 
the  axis  of  the  pelvic  urethra.  This  part  of  the 
urethra  lies  about  1  inch  behind  and  below  the 
pubic  arch.  The  movable  portion  of  the  urethra 
forms,  when  the  penis  is  dependent,  a  curve  in 
the  opposite  direction,  so  that  the  whole  canal 
follows  somewhat  the  outline  of  the  letter  S. 

In  introducing  a  catheter  it  must  be  noted 
that  while  the  instrument  passes  along  the  mov- 
able urethra  the  canal  accommodates  itself  to 
the  catheter,  but  while  traversing  the  fixed  or 
pelvic  segment  the  instrument  must  accommodate 
itself  to  the  unyielding  canal.  In  introducing  a 
catheter  in  the  recumbent  posture  the  penis  is 
held  vertically  upwards,  and  in  this  way  the 
curve  formted  by  the  movable  urethra  is  obliter- 
ated. The  instrument  is  best  kept  close  to  the 


496  ABDOMEN  AND  PELVIS  [CHAP. 

surface  of  the  groin,  and  over  and  parallel  to 
Poupart's  ligament.  When  the  fixed  urethra  is 
reached,  the  handle  of  the  catheter  is  brought  to 
the  middle  line,  and  then,  being  kept  strictly  in 
the  median  plane  of  the  body,  is  depressed  be- 
tween the  legs,  so  that  the  front  of  the  instru- 
ment may  follow  the  natural  curve  of  the  canal. 
The  greatest  difficulty  in  the  introduction  is 
generally  experienced  at  the  point  where  the 
movable  and  fixed  parts  of  the  urethra  meet,  at 
the  anterior  layer  of  the  triangular  ligament 
(Fig.  108).  This  difficulty  is  due  to  three  circum- 
stances: (1)  The  wide  bulbous  urethra  is  suddenly 
contracted  to  the  narrow  membranous  part;  (2) 
the  entrance  to  the  membranous  part  is  pro- 
tected and  closed  by  the  sphincter  urethrse;  if 
there  is  urethritis  the  sphincter  is  thrown  into  a 
state  of  reflex  spasm  at  the  approach  of  the 
catheter,  and  only  yields  to  gentle  and  continuous 
pressure;  (3)  at  its  sphincteric  orifice  the  axis 
of  the  urethra  changes  its  direction.  In  passing 
a  catheter,  even  in  the  normal  urethra,  all  those 
difficulties  have  to  be  negotiated.  When  a  false 
passage  has  been  made  by  a  catheter  in  a  case 
where  no  stricture  exists  to  offer  a  definite  obstruc- 
tion, the  instrument  is  usually  found  to  have 
left  the  canal  just  in  front  of  the  triangular 
ligament. 

The  urethral  canal  must  not  be  regarded 
as  forming  an  open  tube  like  a  gas-pipe.  Except 
when  urine  or  an  instrument  is  passing  along  it, 
the  tube  appears  on  section  as  a  transverse  slit, 
the  superior  and  inferior  walls  being  in  contact. 
This  fact  should  be  remembered  in  amputation  of 
the  penis  by  the  ecraseur.  In  the  fossa  navicu- 
laris  the  tube  appears  as  a  vertical  slit.  The 
mucous  lining  is  kept  in  apposition  by  the  flac- 
cidity  of  the  parts,  and  the  spongy  tissue  and 
non-striated  muscle-fibres  which  form  a  sub- 
stratum to  it. 

The  prostatic  part  of  the  canal  is  the  widest 
and  most  dilatable  portion  of  the  whole  urethra. 


xxi]  MALE   URETHRA  497 

It  is  widest  at  its  centre,  having  here  a  diameter 
of  nearly  &  an  inch;  at  the  bladder  end  its  dia- 
meter is  about  i  of  an  inch,  while  at  the  anterior 
extremity  of  this  part  of  the  urethra  the  measure- 
ment is  a  little  less  than  ^  of  an  inch.  The 
ejaculatory  ducts,  guarded  by  sphincteric  muscles 
(F.  S.  Kidd),  open  into  the  prostatic  urethra, 
and  thus  it  happens  that  inflammation  of  this 
part  of  the  canal  may  spread  back  along  those 
ducts  to  the  seminal  vesicles,  and  thence  along  the 
vas  deferens  to  the  epididymis  (Fig.  108).  It  is 
by  spreading  along  these  parts  that  inflammation 
of  the  testicle  is  set  up  when  gonorrhoea  involves 
the  prostatic  urethra,  and  it  will  be  understood 
that  a  similar  inflammation  may  follow  impacted 
stone  in  the  prostatic  urethra,  prostatic  abscess, 
and  the  like.  Stricture  never  occurs  in  this 
part. 

The  membranous  urethra  is,  with  the  exception 
of  the  meatus,  the  narrowest  part  of  the  entire 
tube.  Its  diameter  is  about  £  of  an  inch.  It  is 
fixed  between  the  two  layers  of  the  triangular 
ligament,  and  is  surrounded  by  the  reflex-acting 
sphincter  urethra.  It  is  at  this  spot,  therefore, 
that  what  is  known  as  "spasmodic  stricture  " 
usually  occurs.  In  any  case,  the  contraction  of 
the  sphincter  (constrictor)  urethrse  often  offers 
an  appreciable  amount  of  resistance  to  the  passage 
of  a  catheter  or  sound. 

The  penile  urethra  is  dilated  at  either  end, 
viz.  at  the  parts  occupying  the  bulb  and  the  glans 
penis  respectively.  The  diameter  of  the  bulbous 
urethra  is  midway  between  those  of  the  prostatic 
and  membranous  segments  of  the  canal,  while  that 
of  the  greater  part  of  the  penile  urethra  is  mid- 
way between  those  of  the  bulbous  and  membran- 
ous portions.  It  is  in  the  bulbous  urethra  that 
organic  stricture  is  thf3  most  commonly  met  with. 
The  meatus  measures  from  £  to  \  of  an  inch, 
and  therefore  if  a  catheter  will  pass  the  meatus 
it  will  pass  along  any  part  of  the  normal  canal. 
Its  aperture  is  very  resisting,  and  has  often  to 


498  ABDOMEN  AND  PELVIS  [CHAP. 

be  incised  to  allow  the  larger  instruments  to 
pass. 

The  narrowest  parts  of  the  urethra,  therefore, 
are  (1)  at  the  meatus,  and  (2)  in  the  membranous 
segment,  especially  at  its  anterior  end.  It  is 
at  these  points  that  calculi  passed  from  the  blad- 
der are  most  apt  to  lodge.  The  widest  portions 
of  the  canal,  on  the  other  hand,  are  at  (1)  the 
fossa  navicularis,  (2)  the  bulbous  part  of  the 
urethra,  and  (3)  the  centre  of  the  prostatic 
portion. 

The  mucous  membrane  may  be  examined  from 
end  to  end  by  means  of  the  urethroscope.  The 
penile  urethra  is  furnished  with  numerous  mucous 
glands,  for  the  greater  part  arranged  along  the 
upper  or  dorsal  wall.  These  glands  supply  a 
lubricant  which  is  necessary  for  the  easy  passage 
of  urine  and  the  protection  of  the  lining  mem- 
brane. When,  however,  the  lining  membrane  be- 
comes the  site  of  infective  inflammation,  these 
glands  and  crypts  become  particularly  affected, 
just  as  is  the  case  in  other  inflamed  mucous 
membranes,  such  as  the  tracheal  and  bronchial; 
their  secretion  becomes  enormously  increased  in 
amount  and  purulent  in  character.  They  become 
harbouring  nests  for  the  gonococcus.  With  the 
urethroscope  their  swollen  condition  can  be  made 
out,  and  the  lacuna  magna  in  the  roof  of  the 
navicular  part  distinguished,  as  can  be  the  colour 
of  the  various  parts  of  the  urethra.  The  openings 
of  the  ducts  of  Cowper  in  the  floor  of  the  bulbous 
urethra  cannot  be  seen  (F.  S.  Kidd),  but  the 
puckering  of  the  mucous  membrane  at  the  entrance 
to  the  membranous  urethra  and  its  closure  by 
the  sphincter  are  readily  made  out.  The  parts 
in  the  floor  of  the  deep  urethra  can  also  be  ex- 
amined—the orifice  of  the  prostatic  utricle  (uterus 
mascuUnus}  and  orifices  of  the  ejaculatory  ducts. 
The  deep  part  of  the  urethra  is  sensitive,  and  it 
is  extremely  important  to  remember  that  the  lining 
membrane  of  this  part  has  a  remarkable  power  to 
absorb  innocuous  as  well  as  noxious  substances. 


xxi]  THE   PENIS  499 

The  urethra  may  be  ruptured  by  the  patient 
falling  astride  of  some  hard. substance.  In  such  an 
injury  it  is  crushed  between  the  hard  substance 
and  the  pubic  arch.  The  part  of  the  canal,  there- 
fore, that  is  most  often  damaged  is  the  mem- 
branous segment,  and  the  posterior  part  of  the 
penile  division.  The  more  the  body  is  bent  for- 
wards at  the  time  the  perineum  is  struck,  the 
greater  is  the  length  of  penile  urethra  that  may  be 
crushed  against  the  pubes. 

The  female  urethra,  is  about  1^  inches  in 
length,  and  has  a  diameter  of  from  |  to  |  of  an 
inch.  It  is  capable,  however,  of  great  distension. 
In  the  erect  position  the  canal  is  nearly  vertical, 
and  in  the  recumbent  posture  almost  horizontal. 
The  penis. — The  skin  covering  the  bulk  of  the 
organ  is  thin  and  fine,  and  the  subcutaneous  tissue 
is  scanty  and  lax.  It  follows,  from  the  looseness 
of  this  tissue,  that  the  skin  is  very  distensible 
and  movable.  The  latter  fact  should  be  borne 
in  mind  in  circumcision,  for  in  performing  that 
operation  the  skin  of  the  penis  can  be  so  readily 
drawn  forwards  over  and  beyond  the  glans,  that 
if  it  is  excised  as  far  back  as  possible  the  greater 
part  of  the  organ  may  be  left  bare.  This  applies, 
of  course,  mainly  to  children.  The  laxity  of 
the  submucous  tissue  permits  the  organ  to  be- 
come enormously  swollen  when  oedematous,  or 
when  extravasated  urine  finds  its  way  into  the 
part.  Over  the  glans  penis  the  mucous  mem- 
brane is  so  a'dherent  that  there  is  practically  no 
subcutaneous  tissue.  It  happens,  therefore,  that 
when  Hunterian  chancres  appear  on  this  part 
they  can  never  be  associated  with  other  than  the 
most  trifling  induration,  there  being  no  tissue  in 
which  the  thickening  can  develop.  At  the  corona, 
on  the  other  hand,  the  submucous  tissue  is  lax 
and  plentiful,  so  that  the  induration  can  readily 
form,  and  it  is  about  this  spot,  therefore,  that  the 
syphilitic  sore  often  attains  its  most  character- 
istic development.  The  vascularity  of  the  penis, 
and  the  rapid  engorgement  that  ensues  when  the 


500 


ABDOMEN  AND  PELVIS 


[CHAP. 


return  of  its  venous  blood  is  impeded,  serve  to 
explain  the  ready  and  extensive  swelling  of  the 
organ  that  follows  when  any  constricting  band  is 
placed  about  it.  This  should  be  borne  in  mind  in 
tying  in  a  catheter  by  securing  it  by  tapes  around 
the  penis.  The  blood  spaces  in  the  corpus  spongi- 
osum  may  be  rendered  indistensible  from  gonor- 
rhceal  inflammation  while  those  of  the  corpora 
cavernosa  remain  free.  The  corpus  spongiosum 
then  acts  like  the  string  of  a  bow  during  the  erec- 
tion of  the  penis.  Through  the  superficial  lym- 
phatics disease  may  spread  from  the  skin  and 
meatal  region  of  the  penis  to  the  inner  of  the 
inguinal  glands.  Deeper  vessels  pass  with  the 


PREPUCE 

CORP.CAVCRNOSUM 

CLAN 
LACUNA  AIAC.NA 

FOSSA  flAVICULARIS 

PERMANENT  MEATU 
PRIMIT 


Fig.    109.  —  Section    of  penis,  showing  a  common  form  of 
hypospadias. 

The  cross  marks  the  point  where  the  tissue  breaks  down  between 
the  cloacal  urethra  and  meatal  ingrowth. 

prostatic  veins  to  the  internal  iliac  group  of 
glands  on  the  lateral  wall  of  the  pelvis.  Some 
vessels  pass  directly  to  the  external  iliac  glands 
through  the  femoral  ring. 

The  penis  is  frequently  the  seat  of  arrests 
of  development,  presenting  a  variety  of  appear- 
ances. Among  them  may  be  mentioned  hypo= 
spadias,  where  the  inferior  wall  of  the  urethra 
and  corresponding  part  of  the  corpus  spongiosum 
are  wanting,  and  epispadias,  where  the  superior 
wall  of  the  canal  and  corresponding  part  of  the 
corpora  cavernosa  are  more  or  less  entirely  de- 
ficient. In  the  condition  of  hypospadias  two 
meati  are  present  —  one  situated  on  the  glans 


xxi]  THE  SCROTUM  501 

opening  into  a  cul-de-sac  which  represents  the 
fossa  navicularis,  and  another  just  behind  lead- 
ing into  the  urethra  (Fig.  109).  Here  is  seen 
the  double  origin  of  the  male  urethra — the  part 
within  the  glans  is  formed  by  an  ingrowth  of 
epithelium  from  the  surface  of  the^  glans,  while 
the  rest  of  the  penile  urethra  is  derived  from  the 
cloaca.  At  first  the  cloaca!  urethra  opens  by  its 
own  orifice  (primitive  meatus,  Fig.  109),  but  in  the 
course  of  development  the  ingrowth  from  the  glans 
takes  place  to  form  the  permanent  meatus  and 
fossa  navicularis;  when  this  ingrowth  opens  into 
the  cloacal  urethra  the  primitive  meatus  becomes 
closed.  The  frenum  preputii  is  formed  over  it. 
The  condition  thus  represented  is  one  of  ar- 
rested development.  On  the  prepuce  of  such  cases 
sebaceous  glands  are  arranged  in  two  pigmented 
oval  groups — preputial  ocelli  (Shillitoe). 

The  scrotum.— The  skin  of  the  scrotum  is 
thin  and  transparent,  so  that  in  bruising  of  the 
parts  the  discoloration  due  to  the  extravasation  of 
blood  beneath  the  surface  is  readily  and  distinctly 
seen.  It  is  also  very  elastic,  and  allows  of  great 
distension,  as  is  seen  in  large  scrotal  hernise 
and  testicular  tumours.  The  integument  of  the 
part  is  indeed  redundant,  and  the  excision 
of  a  portion  of  it  will  hardly  be  missed.  Even 
in  gangrene  of  the  scrotum!,  when  both  testicles 
have  been  exposed,  the  parts  have  been  entirely 
restored  ^  without  any  inconvenient  shrinking  or 
contraction.  The  rugce  on  the  surface  of  the  scro- 
tum favour  the  accumulation  of  dirt,  and  the 
irritation  set  up  by  such  accumulation  may  be 
the  exciting  cause  of  the  epitheliomata  that  are 
not  uncommon  in  this  part.  When  the  surface  is 
sweating,  the  rugae  tend  to  favour  a  retention  of 
the  moisture  between  their  folds ;  from  this  and 
other  circumstances  it  happens  that  the  scrotum 
is  liable  to  eczema  and  to  those  syphilitic  skin 
disorders  that  are  often  localized  by  irritation. 
The  rugae  are  a  sign  of  health,  since  they  depend 
upon  the  vigorous  contraction  of  the  muscle  fibres 


502  ABDOMEN  AND  PELVIS  [CHAP. 

in  the  dartos  tissue.  In  the  enfeebled,  or  under 
the  relaxing  effects  of  heat,  the  scrotum  becomes 
smooth  and  pendulous.  In  a  simple  incised 
wound,  as  in  castration,  the  dartos  is  apt  to  turn 
in  the  edges  of  the  skin  and  cause  some  difficulty 
in  applying  the  sutures.  This  difficulty  may  be 
avoided  by  inducing  the  relaxation  of  that  tissue 
for  a  while  by  the  application  of  a  warm  sponge 
to  the  wound. 

The  subcutaneous  tissue  is  lax  and  very  ex- 
tensive, and  permits  of  considerable  extravasa- 
tions of  blood  forming  beneath  the  surface.  The 
scrotum,  from  its  dependent  position,  and  from 
the  looseness  and  extent  of  its  cellular  tissue, 
is  often  the  first  part  of  the  body  to  become 
oedematous  in  dropsy,  and  is  apt  to  show  that 
oedema  in  a  marked  degree.  The  scrotum  also  ^is 
the  part  most  frequently  the  seat  of  elephantiasis, 
which  is  due  essentially  to  a  distension  of  the 
lymphatic  vessels  and  spaces  of  the  connective 
tissue.  The  vitality  of  the  scrotum  is  not  consider- 
able, and  it  therefore  ^not  infrequently  sloughs  in 
parts  when  severely  inflamed.  For  this  reason 
strapping  should  be  applied  with  some  care  over 
the  enlarged  testis,  for  against  the  hard  mass  of 
the  affected  gland  the  integument  of  the  scrotum 
can  be  subjected  to  considerable  pressure  when  the 
strapping  is  tightly  applied.  In  such  a  case  the 
whole  of  one  side  of  the  scrotum  has  been  seen  to 
slough  from  an  indiscreet  use  of  this  familiar 
method  of  treatment. 

The  testicle  may  be  retained  within  the  ab- 
dominal cavity,  or  may  lodge  for  varying  periods 
of  time,  or  for  life,  in  the  inguinal  canal.  It 
may,  on  the  other  hand,  pass  beyond  the  scrotum 
into  the  perineum,  or  may  miss  the  inguinal  canal 
altogether  and  escape  through  the  femoral  canal 
and  saphenous  opening  on  to  the  thigh  (see  p.  370). 
The  testis  proper  is  entirely  inyostod  by  tho 
visceral  layer  of  the  tunica  yaginalis,  except  over 
a  small  part  of  its  posterior  border  where  the 
vessels  enter.  The  epididymis  is  entirely  covered 


xxi]  THE  TESTICLE       .  503 

by  the  serous  membrane  at  its  sides,  is  more  or 
less  so  covered  in  front,  but  is  free  or  uncovered 
along  the  greater  part  of  its  posterior  border  (see 
Fig.  83,  p.  371).  It  is  about  the  posterior  border 
of  the  epididymis  that  the  visceral  layer  of  the 
tunica  vaginalis  joins  the  parietal  layer.  The 
posterior  border  of  the  testicle  and  of  the  epi- 
didymis—from  globus  major  to  globus  minor — is 
bound  by  a  reflection  of  serous  membrane — the 
mesentery  of  the  testicle.  Instead  of  binding  the 
whole  of  the  posterior  border,  the  mesentery  may 
be  attached  merely  to  the  lower  pole  of  the 
testicle  and  globus  minor ;  on  such  a  pedunculated 
attachment  the  testicle  is  apt  to  become  stran- 
gulated by  a  twisting  of  its  narrow  mesentery. 
A  narrow,  elongated  mesentery  is  found  only  in 
glands  which  are  late  in  descending  or  have  been 
arrested  in  their  descent ;  torsion  of  the  testicle 
is,  therefore,  only  possible  in  imperfectly  de- 
veloped organs.  The  more  intimate  and  exten- 
sive connexion  of  the  serous  tunic  with  the  testis 
or  gland  proper  serves  in  part  to  explain  the 
greater  frequency  with  which  hydrocele  appears 
in  inflammation  of  this  part  of  the  organ,  as 
compared  with  its  occurrence  when  the  epididy- 
mis is  alone  inflamed.  It  is  owing  to  the  reflec- 
tions of  the  tunica  vaginalis  that  in  cases  of 
common  hydrocele  the  testicle  remains  firmly  set 
at  the  lower  and  posterior  part  of  the  swelling, 
and  yet  so  extensively  is  the  organ  surrounded 
by  that  membrane  that  the  position  of  the  gland 
in  the  larger  hydroceles  is  often  difficult  to  deter- 
mine. In  some  cases  the  testicle  occupies  the  front 
of  the  scrotum,  the  epididymis  being  placed  an- 
teriorly, and  the  body  of  the  gland  being  located 
behind  it.  The  vas  deferens  descends  also  along 
the  front  of  the  cord.  In  these  cases  the  testicle 
is  just  in  the  position  it  would  occupy  if  it  had 
been  turned  round  upon  its  vertical  axis.  The 
condition  is  known  as  inversion  of  the  testicle, 
and  should  be  sought  for  in  cases  of  hydrocele, 
as  in  several  instances  the  testis  has  been  pierced 


504  ABDOMEN  AND  PELVIS  [CHAP. 

by  the  trocar  when  tapping  collections  in  cases 
where  the  inversion  existed. 

The  proper  gland  tissue  is  invested  by  a  very 
dense  membrane,  the  tunica  albuginea.  The  epi- 
didymis, on  the  other  hand,  lacks  any  such  firm 
fibrous  investment.  The  unyielding  character  of 
the  tunica  jalbuginea  serves  in  great  part  to  ex- 
plain the  intense  pain  felt  in  acute  affections 
of  the  testis  proper,  a  degree  of  pain  which  is 
not  reached  when  the  less  tightly  girt  epididymis 
is  alone  involved.  It  will  be  understood  also  that 
in  inflammation  of  the  epididymis  the  part  swells 
rapidly  and  extensively,  while  in  a  like  affection 
of  the  body  of  the  gland  the  swelling  is  compara- 
tively slow  to  appear. 

It  should  be  borne  in  mind  that  the  lymphatics 
of  the  scrotum  go  to  the  inguinal  glands,  those  of 
the  testicle^  to  the  lumbar ;  in  malignant  disease 
of  the  testicle  the  secondary  deposits  are  to  be 
expected  deep  within  the  abdomen  by  the  side  of 
the  aorta.  The  testicle  is  developed  in  front 
of  the  tenth  dorsal  vertebra,  and  receives  its  nerve 
supply  from  the  tenth  dorsal  segment.  Its  nerves 
pass  by  the  small  splanchnics,  solar  and  aortic 
plexuses,  to  the  spermatic  artery,  on  which  they 
reach  the  gland.  The  epididymis  receives  its 
nerve  supply  from  the  pelvic  plexus,  along  the 
vas  deferens. 

Spermatic  cord, —  The  structures  in  the 
cord  are  (1)  the  vas  deferens,  (2)  the  cremaster 
muscle,  (3)  the  spermatic  and  (4)  cremasteric 
arteries,  (5)  the  artery  to  the  vas  deferens, 
(6)  the  pampiniform  plexus  of  veins,  (7)  the 
genito-crural  nerve,  (8)  sympathetic  nerve  fibres, 
and  (9)  lymphatics.  The  vas  deferens  (ductus 
deferens)  lies  along  the  posterior  aspect  of  the 
cord  (Fig.  110),  and  can  be  detected  by  the  firm, 
cord-like  sensation  which  it  gives  when  pinched 
between  the  thumb  and  finger.  Mr.  Birkett 
(Holmes's  "  System  ")  gives  three  cases  of  rupture 
of  the  vas  deferens  during  severe  and  sudden 
exertion.  The  duct  appears  to  have  in  each  case 


XXI] 


SPERMATIC   CORD 


505 


given  way  within  the  abdomen  at  some  point 
between  the  internal  ring  and  the  spot  where 
it  approaches  the  ureter.  Resection  of  part  of 
the  vas  has  been  practised  to  bring  about  atrophy 
of  enlarged  prostate,  but  has  not  proved  success- 
ful. The  size  of  the  cremaster  muscle  depends 
mainly  upon  the  weight  it  has  to  suspend.  In 
atrophy  of  the  testicle  it  almost  entirely  dis- 
appears, while  in  cases  of  large  slow-growing 


POSTERIOR 


APT.  or  VAS^ 


VAS  DEFER  a 


SPERM.  ART. 


SPERM.  VEINS 


NT.  SPERM.  FASCIA 


CREMASTERIC 
FASCIA 


EXTERN.  SPERM. 
FASCIA 


ANTERIOR 

Fig.  110. — Section  of  the  left  spermatic  cord  of  an  adult,  at 
the  level  of  the  external  abdominal  ring,  viewed  from 
above. 

tumours  of  the  gland  it  attains  considerable 
proportions.  Of  the  arteries,  the  spermatic  comes 
from  the  aorta  and  lies  in  front  of  the  vas,  the 
cremasteric  arises  from  the  deep  epigastric  and 
lies  among  the  superficial  layers  of  the  cord  in  its 
outer  segment,  while^ihe  deferential  artery ^  from 
the  superior  or  inferior  vesical  lies  by  the  side  of 
the  vas  (Fig.  110).  The  first-named  vessel  is  the 
size  of  the  posterior  auricular,  and  the  two  latter 
the  size  of  the.  supraorbital.  The  spermatic  artery 


506  ABDOMEN  AND  PELVIS  [CHA£. 

divides  into  a  number  of  branches  as  it  reaches 
the  testicle;  these  branches  pass  to  the  inner  side 
of  the  epididymis,  which  may  be  removed  without 
interfering  with  the  blood  supply  of  the  testicle. 
The  three  arteries  of  the  cord  are  divided  in 
castration,  and  may  all  require  ligature.  It  is 
advisable  to  secure  the  vessels  in  sections,  rather 
than  adopt  the  clumsy  plan  of  involving  the  whole 
cord  in  one  common  ligature.  The  veins  are 
divided  roughly  into  two  sets.  The  anterior  is 
by  far  the  larger  set,  runs  with  the  spermatic 
artery,  and  forms  the  pampiniform  plexus.  The 
posterior  set  is  small  and  surrounds  the  vas, 
running  with  the  deferential  artery.  The  veins 
of  the  spermatic  and  pampiniform  plexus  are 
very  frequently  varicose,  and  then  constitute  the 
affection  known  as  varicocele.  Many  anatomical 
causes  render  these  veins  liable  to  this  affection  : 
they  occupy  a  dependent  position,  and  the  main 
vein  is  of  considerable  length,  and  follows  a 
nearly  vertical  course ;  the  vessels  are  very  large 
when  compared  with  the  corresponding  artery, 
and  so  the  vis  a  tergo  must  be  reduced  to  a  mini- 
mum; they  occupy  a  loose  tissue,  and  are  lacking 
in  support  and  in  the  aid  afforded  to  other  veins 
(as  in  the  limbs)  by  muscular  contraction;  they 
are  very  tortuous,  form  many  anastomoses,  and 
have  few  and  imperfect  valves;  they  are  exposed 
to  pressure  in  their  passage  through  the  inguinal 
canal.  The  left  veins  are  more  frequently  affected 
than  the  right.  Mr.  Spencer  has  shown  that  the 
veins  of  the  left  cord  are  always  much  larger 
than  those  of  the  right.  It  may  also  be  pointed 
out  that  the  left  testicle  hangs  lower  than  the 
right;  that  the  left  spermatic  vein  enters  the  left 
renal  at  a  right  angle,  while  the  right  spermatic 
vein  passes  obliquely  into  the  vena  cava ;  and  that 
the  left  vein  passes  beneath  the  sigmoid  colon, 
and  is  thus  exposed  to  pressure  from  the  contents 
of  that  bowel. 

The     female     generative    organs     require 
but    little    notice    in    the    present    volume.       The 


xxi]         FEMALE   GENERATIVE   ORGANS          507 

labia  majora  have  the  same  pathological  tenden- 
cies as  has  the  scrotum,  to  which,  indeed,  they 
anatomically  correspond.  They  are  liable  to 
present  large  extravasations  of  blood,  are  greatly 
swollen  when  cedematous,  are  prone  to  slough 
when  acutely  inflamed,  and  are  the  usual  seats  of 
elephantiasis  in  the  female.  A  hernia  may  pre- 
sent in  one  or  other  labium  (pudendal  hernia), 
the  neck  of  the  sac  being  between  the  vagina  and 
the  pubic  ramus.  Of  such  a  hernia  the  ovary  is 
frequently  a  content. 

"  On  everting  one  of  the  labia  minora  and 
pressing  the  hymen  inwards,  a  small  red  de- 
pression may  generally  be  seen  on  the  vulva, 
somewhat  posteriorly.  It  leads  to  the  orifice  for 
Bartholin's  gland  "  (Doran).  This  gland,  an  oval 
body  about  ^  an  inch  in  length,  lies  against  the 
posterior  part  of  the  vaginal  orifice,  under  the 
superficial  perineal  fascia,  and  covered  by  the 
fibres  of  the  sphincter  vaginae.  It  wastes  after  30. 
It  corresponds  to  the  gland  of  Cowper  in  the 
male  (Fig.  108,  p.  492).  Both  are  apt  to  become 
the  sites  of  chronic  gonorrhceal  inflammation. 
Abscess  of  the  gland  and  cystic  dilatation  of  its 
duct  are  not  uncommon. 

The  vagina  is  lodged  between  the  bladder  and 
rectum,  while  the  upper  fourth  of  its  posterior 
surface  is  covered  with  peritoneum,  and  is  there- 
fore in  relation  to  the  abdominal  cavity.  Thus  it 
happens  that  the  bladder,  the  rectum,  or  the 
small  intestines  may  protrude  into  the  vagina  by 
a  yielding  of  some  parts  of  its  walls  and  thus  pro- 
duce a  vaginal  cystocele,  rectocele,  or  enterocele. 

The  anterior  wall  of  the  vagina  measures  a 
little  over  2  inches,  the  posterior  wall  about  3 
inches.  The  long  axis  of  the  canal  forms  an  angle 
of  60°  with  the  horizon,  and  is  therefore  almost 
parallel  to  the  pelvic  brim.  The  loose  areolar 
tissue  at  the  base  of  the  broad  ligament  lies  on 
each  side  of  the  upper  extremity  of  the  vagina. 
The  ureter  terminates  in  the  bladder,  on  the 
upper  part  of  the  vaginal  roof.  (For  structures 


508  ABDOMEN  AND  PELVIS  [CHAP. 

concerned  in  supporting  the  contents  of  the  female 
pelvis,  see  p.  473.) 

The  abdominal  cavity  may  be  opened  through 
a  wound  of  the  vagina.  In  one  or  two  instances 
of  such  injuries  several  feet  of  intestine  have  pro- 
truded through  the  vulva.  In  one  reported  case 
an  old  woman,  the  subject  of  a  brutal  rape, 
walked  nearly  a  mile  with  several  coils  of  the 
small  bowel  hanging  from  her  genitals. 

From  the  comparative  thinness  of  the  walls 
that  separate  the  vagina  from  the  bladder  and 
rectum,  it  happens  that  vesico-vaginal  and  recto- 
vaginal  nstulse  are  of  frequent  occurrence.  The 
vagina  is  very  vascular,  and  wounds  of  its  walls 
have  led  to  fatal  haemorrhage.  It  is  very  dilat- 
able, as  can  be  shown  when  the  canal  is  plugged 
to  arrest  haemorrhage  from  the  uterus. 

The  uterus  weighs  about  1  oz.  The  uterine 
cavity  and  the  cervical  canal  together  measure 
about  2^  inches.  This  must  be  borne  in  mind 
when  a  uterine  sound  is  being  passed.  The  blood- 
vessels run  transversely  to  the  length  of  the 
uterus,  so  that  a  ligature  may  be  placed  com- 
pletely around  the  organ  without  affecting  the 
circulation  above  or  below.  Ligature  of  the  uterine 
artery  has  been  practised  to  arrest  the  growth  of 
uterine  tumours.  The  artery  rises  from  the  in- 
ternal iliac  \  an  inch  below  the  pelvic  brim,  and 
passes  to  the  neck  of  the  uterus  in  the  broad  liga- 
ment; it  is  2|  inches  long  and  loops  over  the 
ureter  midway  in  its  course.  It  is  reached  by 
incising  the  broad  ligament  between  the  Fallopian 
tube  behind  and  the  round  ligament  in  front;  it 
is  found  in  the  loose  areolar  tissue  under  the 
wound. 

The  lymphatics  from  the  fundus  of  the  uterus 
and  appendages  pass  to  the  lumbar  glands,  a  few 
also  pass  along  the  round  ligament  to  the  in- 
guinal glands.  The  lymphatics  of  the  cervix, 
which  is  frequently  the  seat  of  cancer,  pass  to 
the  internal  iliac  glands  on  the  lateral  wall  of 
the 


xxi]  THE   OVARY  509 

The  unimpregnated  uterus  is  very  rarely 
wounded,  owing  its  immunity  to  the  denseness  of 
its  walls,  to  its  small  size,  to  its  great  mobility, 
and  to  its  position  within  the  bony  pelvis. 

The  ovary  is  so  placed  that  the  outer  part  of 
the  Fallopian  tube  turns  d9wnwards  externally  to 
it.  The  more  common  position  of  the  ovary  may 
be  indicated  on  the  surface  of  the  body  by  the 
line  employed  to  mark  out  the  course  of  the 
common  and  external  iliac  arteries— a  line  drawn 
from  the  aortic  bifurcation  to  the  femoral  point 
(Fig.  81,  p.  367).  The  ovary  lies  internally  to 
the  mid-point  of  this  line  (Fig.  103,  p,  457), 
near  the  angle  between  the  external  and  internal 
iliac  arteries;  it  may  be  indistinctly  palpated 
through  the  vagina.  Its  nerves  come  from  the 
tenth  dorsal  segment  of  the  cord.  The  sensory 
nerves  for  the  cervix  are  derived  from  the  lower 
sacral  segments.  The  lymphatics  of  the  ovary 
pass  to  the  lumbar  glands,  which  lie  by  the  side 
of  the  lower  part  of  the  aorta  and  vena  cava  in 
the  retroperitoneal  tissue.  The  ovaries  exert  a 
very  marked  trophic  influence  on  the  breast;  the 
hypertrophy  of  the  mammae  at  puberty  and  in 
pregnancy  depends  on  an  internal  secretion  of 
the  ovary  (Starling).  By  their  removal  it  was 
hoped  that  cancer  01  the  breast  might  be  arrested, 
but  the  procedure  has  not  been  followed  by  much 
success.  At  the^  brim  of  the  pelvis  the  ovarian 
vessels  lie  within  a  fold  of  peritoneum,  named 
the  ovario-  or  infundibulo-pelvic  ligament,  for  it 
is  attached  both  to  the  ovary  and  to  the  infundi- 
bulum  of  the  Fallopian  tube.  This  ligament 
forms  the  outer  part  of  the  pedicle  in  ovariotomy. 

The  various  vestigial  structures  connected  with 
the  ovary — structures  which  may  become  dilated 
into  cysts — are  shown  in  Fig.  111.  Such  vestiges 
correspond  to  structures  which  are  fully  developed 
in  the  male  and  form  part  of  the  elaborate  system 
of  ducts  that  convey  semen  from  the  tubules  of 
the  testicle  to  the  urethra.  Thus  the  ductus  (vas) 
deferens  is  represented  by  the  Wolffian  duct,  lying 


510 


ABDOMEN  AND  PELVIS 


[CHAP. 


between  the  layers  of  the  broad  ligament;  the 
Wolffian  tubules,  passing  towards  the  hilus  of 
the  ovary,  correspond  to  the  vasa  efferentia  of  the 
male;  the  rete  testis,  which  lies  in  the  medias- 
tinum of  the  testicle  and  serves  to  convey  the 
semen  from  the  seminiferous  tubules  _  to  the  vasa 
efferentia,  is  represented  at  the  hilus  of  the 
ovary  and  along  the  ovarian  fimbria  of  the  tube 
by  isolated  structural  elements.  Two  of  these 
elements,  the  efferent  ducts  and  rete  channels, 
are  developed  as  independent  structures,  and  only 


STALKED   HYOAT. 
SCSSILE   HYOATID 


TERINf    TUBE 


E-POOPHOBDN 


SOLAT,    TUBULE 


GUBERNACULUM 


Fig.  111. — A,  Diagram  of  the  vestigial  structures  con- 
nected with  the  testicle — occasionally  the  sites  of 
cystic  formation.  B,  Corresponding  diagram  of  the 
vestigial  parts  connected  with  the  ovary. 

at  a  later  stage  of  development  effect  a  union 
with  the  neighbouring  parts  of  the  duct  system. 
In  the  female  a  considerable  number,  and  in  the 
male  a  few,  of  these  structural  elements  persist 
as  isolated  rudiments  of  tubules,  and  thus  may 
become  the  site  of  cyst  formations. 

The  rectum  commences  in  front  of  the  third 
sacral  vertebra,  and  is  about  5  inches  in  length 
(Fig.  112).  It  is  continuous  at  the  pelvi-rectal 
constriction  with  the  pelvic  colon,  which  is  in- 
vested by  peritoneum  and  supported  by  a  mesen- 


THE   RECTUM 


511 


tery-  The  serous  membrane  gradually  leaves  the 
posterior  surface  of  the  rectum,  then  its  sides,  and 
lastly  its  anterior  surface.  Anteriorly,  the  peri- 
toneum, in  the  form  of  the  recto-vesical  pouch, 
extends  in  the  male  to  within  3  inches  of  the  anus, 
while  on  the  posterior  aspect  of  the  gut  there  is 
no  peritoneum  below  a  spot  5  inches  from  the 
anus.  Thus,  in  excision  of  the  rectum,  more  of 


PELVIC  COLON 


MID.  RECTAL  FOLD 


EXT.  SPHINC. 
ANAL  VALVES 


ANAL  COLUMNS 
INT.  SPHINC. 


Fig.  112. — The  stages  of  the  rectum  and  the  anal  canal  on 
mesial  section.     (Prof.  A.  M.  Pater  son.} 

the  bowel  can  be  removed  in  the  posterior  than 
in  the  anterior  part  of  the  tube  without  opening 
the  peritoneal  cavity.  It  will  be  seen,  also,  that 
carcinomatous  and  other  spreading  ulcers  are 
more  apt  to  invade  the  peritoneal  cavity  when 
they  are  situated  in  the  anterior  wall  of  the 
intestine.  The  lowest  part  of  the  rectum,  distin- 
guished as  the  anal  canal,  is  surrounded  by  the 


512  ABDOMEN  AND  PELVIS  [CHAP. 

internal  sphincter — an  involuntary  muscle  that  is 
continuous  with  the  circular  coat.  In  a  state 
of  rest  the  anal  canal,  which  is  directed  down- 
wards and  backwards,  measures  H  inches,  but 
during  defsecation  and  when  the  patient  bears 
down  it  assumes  a  shallow  annular  form.  The 
canal  is  firmly  fixed  to  the  levatores  ani  and 
perineal  body,  hence  in  prolapse  it  is  the  rectum 
above  the  canal  which  is  extruded  through  the 
anus.  Mr.  Cripps  has  shown  that  the  posterior 
edge  of  the  levator  aiii  forms  a  distinctly-felt 
free  border,  which  crosses  the  rectum,  nearly  at 
a  right  angle,  at  a  point  H-2  inches  from  the 
anus. 

By  inserting  the  finger  into  the  rectum  the 
prostate  and  seminal  vesicles  can  be  readily  felt 
and  examined,  and  that  triangular  surface  of  the 
bladder  explored  through  which  puncture  per 
rectum  is  made  (p.  486). 

It  will  be  understood  that  the  prostate,  when 
enlarged,  may  encroach  upon  the  cavity  of  the 
rectum  and  greatly  narrow  its  lumen  (Fig.  108). 
The  position  of  the  seminal  vesicles  with  regard 
to  the  bowel  is  such  that  in  violent  attempts  at 
defsecation  they  may  be  pressed  upon  by  the  rectal 
contents,  and  so  in  part  emptied,  producing  a 
kind  of  spermatorrhoea.  Defsecation  also  often 
causes  much  pain  in  inflammatory  affections  of 
the  prostate  and  adjacent  parts. 

The  anterior  surface  of  the  rectum  in  the 
female  is  in  relation,  so  far  as  the  finger  can 
reach,  with  the  vagina,  and,  in  examining  the 
lower  part  of  the  rectum,  it  is  convenient  to  pro- 
trude its  mucous  membrane  through  the  anus  by 
means  of  the  finger  introduced  into  the  genital 
passage. 

From  a  functional  as  well  as  a  morphological 
point  of  view  the  rectum  is  divided  into  two 
parts — an  upper,  in  relationship  with  the  peri- 
toneum and  the  recto-vesical  pouch,  dilatable, 
and,  before  defsecation,  laden  with  faeces ;  and  a , 
lower,  which  is  beyond  the  peritoneum  and  serves 


xxi]  THE  RECTUM  513 

merely  for  the  passage,  not  the  storage,  of  faeces 
(Wood- Jones).  Advantage  of  this  circumstance 
is  taken  in  operations  for  the  cure  of  ectopia 
vesicse  where  the  ureters  are  removed  from  the 
exposed  bladder  and  implanted  in  the  rectum.  It 
is  the  distension  of  the  upper  rectum  which  gives 
a  sense  of  fullness  and  sets  in  train  the  voluntary 
and  involuntary  efforts  of  defsecation. 

Faeces  may  become  impacted  in  the  rectum. 
Strange  bodies,  too,  are  frequently  found  mis- 
placed within  it.  Among  the  latter  may  be  men- 
tioned a  bullock's  horn,  an  iron  match-box,  and 
a  glass  tumbler.  By  antiperistaltic  movements 
of  the  rectum  and  colon,  such  bodies  may  be 
carried  towards  the  caecum.  Thus  a  case  has 
been  reported  by  Alexander  in  which  the  handle 
of  an  umbrella,  accidentally  lodged  in  the  rectum, 
was  removed  by  a  surgeon,  two  weeks  later,  from 
the  hepatic  flexure  of  the  colon.  Experiment  has 
shown  that  when  the  rectum  is  distended  in  the 
male,  the  recto-vesical  fold  of  peritoneum  is 
raised,  and  the  bladder  is  elevated  and  pushed 
forwards.  In  the  female  the  fundus  uteri  is 
raised  and  pushed  towards  the  symphysis.  The 
rectum  is  artificially  distended  in  suprapubic 
lithotomy,  in  order  to  bring  the  bladder  into 
better  position  (p.  483). 

If  the  sphincters  of  the  anus  be  very  gradually 
dilated,  the  entire  hand,  if  small,  may  be  intro- 
duced into  the  rectum  in  both  males  and  females; 
but  in  several  cases,  when  so  dilated,  it  has  been 
found  that  the  sphincter  never  regains  its  normal 
action.  The  circumference^of  the  hand  should  not 
exceed  8  inches.  By  a  semi-rotary  movement,  and 
by  alternately  flexing  and  extending  the  fingers, 
the  hand  can  be  insinuated  into  the  commence- 
ment of  the  pelvic  colon.  Owing  to  the  mobility 
of  this  part  of  the  bowel  a  larere  extent  of  the 
abdomen  may  be  explored  through  the  bowel  wall. 
The  structures  that  can  be  readily  felt  are  the 
kidneys,  ^the  aorta,  the  iliac  vessels,  the  uterus 
and  ovaries,  the  bladder  and  its  surroundings,  the 
B 


514  ABDOMEN  AND  PELVIS  [CHAP. 

pelvic  briin,  the  sacro-sciatic  foramina,  the  ischial 
spine,  the  sacrum,  etc.  In  some  subjects  even  a 
small  hand  cannot  be  passed  beyond  the  reflection 
of  the  peritoneum  over  the  second  part  of  the 
gut.  In  such  instances  the  peritoneum  offers  a 
resistance  like  a  tight  garter,  and  prevents  the 
farther  advance  of  the  hand  without  great  risk 
of  laceration  of  the  parts  (Walsham).  Owing  to 
the  constrained  position  of  the  hand  and  the 
cramping  of  the  fingers,  this  method  of  examina- 
tion has  proved  to  be  of  but  limited  service. 

The  attachments  of  the  rectum  by  means  of 
its  sheath  to  the  pelvic  fascia  are  not  very  firm ; 
fibrous  prolongations  from  the  perivascular  sheath 
accompany  the  middle  hsemorrhoidal  vessels,  and 
fibrous  bands  from  the  sacrum  also  join  its  sheath 
and  have  to  be  severed  in  the  operation  of  excision. 
The  laxity  of  its  attachment  is  shown  in  some 
cases  where  the  gut  has  been  protruded  at  the 
anus.  In  excision  of  the  rectum,  also,  advantage 
is  taken  of  this  mobility. 

The  mucous  membrane  is  thick,  vascular,  and 
but  loosely  attached  to  the  muscular  coat  be- 
neath. This  laxity,  which  is  more  marked  in 
children,  favours  prolapse,  an  affection  in  which 
the  mucous  membrane  of  the  lower  part  of  the 
rectum  is  protruded  at^the  anus.  At  the  junction 
of  the  rectum  and  pelvic  colon  there  is  a  circular 
fold  or  valve,  and  often  the  musculature  here  is 
constricted  and  acts  functionally  as  a  sphincter 
(Fig.  112).  Ab9ve  the  base  of  the  prostate  (Fig. 
112)  the  anterior  wall  of  the  rectum,  at  the 
junction  of  its  upper  and  lower  parts,  is  folded 
within  the  lumen  of  the  gut  to  form  a  transverse 
fold,  often  named  after  Houston  who  described  it. 
These  rectal  folds  or  valves,  especially  when  the 
gut  is  empty,  may  offer  considerable  resistance  to 
the  introduction  of  a  bougie  or  long  enema  tube, 
and  their  position  should  be  therefore  borne 
in  mind. 

The  vessels,  and  especially  the  veins,  at  the 
lower  part  of  the  rectum  are  apt  to  become  vari- 


xxi]  HAEMORRHOIDS  515 

cose  and  dilated,  and  form  piles.  The  tendency 
to  piles  can  in  part  be  explained  by  the  dependent 
position  of  the  rectum,  by  the  pressure  effects  of 
hardened  faeces  upon  the  returning  veins,  and  by 
the  fact  that  part  of  the  venous  blood  returns 
through  the  systemic  system  (internal  iliac  vein) 
and  part  through  the  portal  system  (inferior 
inesenteric  vein).  This  connexion  with  the  portal 
trunk,  which  is  not  an  extensive  one,  may 
cause  the  rectum  to  participate  in  the  many 
forms  of  congestion  incident  to  that  vein.  The 
veins  of  the  rectum  can  also  be  affected  by 
violent  expiratory  efforts.  In  the  lower  part  of 
the  rectum — the  extraperitoneal  part,  which  is 
some  3-4  inches  in  length — the  arrangement  of  the 
vessels  is  peculiar,  and  is  such  as  to  favour  vari- 
cosity.  The  arteries,  "  having  penetrated  the 
muscular  coats  at  different  heights,  assume,  in 
this  segment,  a  longitudinal  direction,  passing 
in  parallel  lines  towards  the  edge  of  the  bowel 
within  the  submucous  coat.  In  their  progress 
downwards  they  communicate  with  one  another  at 
intervals,  and  they  are  very  freely  connected  near 
the  orifice,  where  all  the  arteries  join,  by  trans- 
verse branches  of  considerable  size."  (Quain.) 
The  branches  of  the  superior  haemorrhoidal  ar- 
teries terminate  in  the  submucous  tissue  of  the 
anal  canal,  forming  vascular  columns  which 
extend  to  the  anus.  The  veins  form  a  plexus 
with  a  precisely  similar  arrangement.  The  veins 
beneath  the  mucous  membrane  of  the  anal  canal 
perforate  the  muscular  coat  of  the  rectum  about 
an  inch  above  the  anal  canal.  At  the  point  of 
perforation  they  are  liable  to  be  compressed. 

The  lymphatics  of  the  rectum  perforate  the 
muscular  coat  and  ascend  in  its  sheath,  where, 
on  the  posterior  aspect,  there  may  be  one  or 
more  glands.  They  join  the  efferent  vessels  of 
the  colon  in  the  mesentery  of  the  pelvic  colon. 
They  also  pass  to  the  internal  iliac  group  of 
lymphatic  glands  on  the  lateral  wall  of  the  pelvis 
and  to  the  lumbar  glands.  Hence,  in  cancer  of 


516  ABDOMEN  AND  PELVIS  [CHAP. 

the  lower  part  of  the  rectum  these  glands  and 
the  vessels  leading  to  them  are  the  earliest  seats 
of  secondary  infections.  The  lymphatics  of  the 
pelvic  colon  pass  to  the  glands  in  front  of 
the  sacrum  and  to  others  between  the  layers 
of  the  meso-rectum. 

The  rectum  may  be  most  freely  exposed  from 
behind  (Figs.  102,  p.  455,  105,  p.  476,  and  112).  In 
Kraske's  operation  for  the  extirpation  of  cancer 
of  the  rectum  an  incision  is  made  along  the 
sacrum  in  the  middle  line,  from  the  level  of 
the  posterior  inferior  iliac  spine  to  the  anus.  A 
flap  is  turned  out  on  the  left  side,  including 
the  skin  and  origin  of  the  gluteus  maximus.  The 
attachments  of  the  left  sacro-sciatic  ligaments, 
coccygeus,  and  levator  ani  to  the  sacrum  and 
coccyx  are  divided  and  turned  outwards.  The 
lateral  and  median  sacral  arteries  and  a  plexus 
of  veins  are  raised  with  the  fibrous  tissue  from 
the  anterior  surface  of  the  sacrum  by  a  peri- 
osteal  elevator.  The  left  halves  of  the  fourth  and 
fifth  sacral  vertebrae,  with  the  left  half  of  the 
coccyx,  are  removed.  The  fourth  and  fifth  sacral 
and  coccygeal  nerves  are  necessarily  cut,  but  an 
attempt  should  be  made  to  save  the  third  sacral 
nerve,  owing  to  the  importance  of  its  function. 
The  rectum  is  then  exposed,  with  the  haeinor- 
rhoidal  vessels  and  reflection  of  peritoneum.  By 
opening  the  peritoneal  cavity  part  of  the  pelvic 
colon  may  be  brought  into  the  wound.  As  will 
be  seen  from  Fig.  113,  there  is  a  risk,  when 
removing  the  rectum,  of  injuring  the  blood  supply 
of  the  pelvic  colon.  If  the  superior  hsemorrhoidal 
artery  be  tied  at  the  base  of  the  mesentery  of 
the  pelvic  colon,  the  arteries  to  the  distal  part 
are  very  liable  to  be  included  in  the  ligature 
(J.  W.  Smith).  After  the  diseased  part  is 
removed,  with  the  presacral  and  internal  iliac 
lymphatic  glands,  the  lower  end  of  the  pelvic 
colon  is  brought  down  and  sutured  to  the  anal 
part.  An  attempt  should  be  made  to  save  the 
levator  ani  as  well  as  the  third  sacral  nerve,  in 


xxi] 


EXCISION   OF  THE   RECTUM 


517 


order  that  the  integrity  of  the  pelvic  diaphragm 
may  be  maintained.  For  a  complete  removal  of 
secondary  deposits  in  the  lymphatic  system  of 
the  rectum,  the  sacral  operation  is  usually  com- 
bined with  an  abdominal  section. 

The  rectum  is  supplied  with  sensory  and  motor 


INF.MESENTERIC   ARTERY 


DESC.COLOM 


S^LUMBAR 
SUP.  H^EMORRH. 


SACRAL  V/SCER.N. 


ARTERIES  TO 
S/GMOID 

SIGMOID    COLON 


POSITION  OF 

HZRVES  IN 
STALK 


SYMPHYSIS 


RECTUM 


Fig.    113. — Diagrammatic    representation    of    the    arterial 
supply  of  the  pelvic  colon  and  rectum.     (Wing ate  Todd.) 

nerves  from  the  second,  third,  and  fourth  sa- 
cral segments,  through  the  corresponding  nerves. 
Motor  nerves  are  also  derived  from  the  lower  two 
dorsal  and  upper  lumbar  segments ;  they  reach 
the  rectum  through  the  hypogastric  and  pelvic 
plexuses.  The  reflex  act  of  defalcation  depends 
not  only  on  these  nerves  being  intact,  but  also 


518  ABDOMEN  AND  PELVIS  [CHAP. 

on  the  functional  activity  of  the  defecation  centre 
in  the  lumbar  part  of  the  spinal  cord. 

The  amis. — The  skin  about  the  anus  is  thrown 
into  numerous  folds,  and  in  these  ulcer  or  fissure 
of  the  anus  forms.  Within  the  anal  canal  the 
mucous  membrane  of  the  lower  rectum  is  thrown 
into  vertical  folds — the  columns  of  Mprgagni. 
When  the  canal  is  dilated  they  are  obliterated, 
and  as  age  advances  they  become  less  well  marked. 
As  is  shown  in  Figs.  106  and  112,  the  columns 
end  at  a  ring  of  minute  transverse  folds  or 
valves,  the  anal  valves,  situated  opposite  the 
lower  border  of  the  internal  sphincter.  When 
the  anus  is  closed,  the  mucous  membrane  lining 
it,  covered  by  stratified  epithelium,  is  also  thrown 
into  folds,  which  ascend  to  the  anal  valves;  at 
the  anal  valves  the  columnar  epithelium  of  the 
lowest  part  of  the  rectum,  the  anal  canal,  meets 
the  stratified  epithelium  of  the  anal  mucous 
membrane.  The  valves  mark  the  point  where  the 
termination  of  the  rectum  opened  into  the  procto- 
dseal  depression  in  the  course  of  development. 

When  the  anal  canal  is  closed,  the  columns 
and  valves  come  together  and  so  make  the  anal 
orifice  competent.  The  valves  may  be  torn  by 
the  passage  of  scybalous  masses,  and  from  the  rent 
thus  caused  a  fissure  of  the  anus  may  be  pro- 
duced (Ball).  The  extreme  painfulness  of  these 
ulcers  is  due  to  the  exposure  of  a  nerve  fibre 
at  their  base,  and  to  the  constant  contraction 
of  the  sphincter  muscle  which  they  excite.  In 
90  per  cent,  of  cases  of  pruritus  ani  there  is 
a  small  ulcer  in  the  posterior  wall  of  the  anal 
canal,  near  the  anal  valves  (F.  C.  Wallis).  Relief 
is  given  by  excising  the  base  of  the  ulcer,  so  as 
to  divide  some  part  of  the  sphincter;  or  by 
violently  dilating  the  anus,  so  as  to  tear  up  the 
base  of  the  ulcer  and  paralyse  for  a  while  the 
action  of  the  disturbing  muscle. 

The  anus  may  be  torn  during  defsecation  when 
the  stools  are  hard.  A  case  is  reported  of  a 
woman  who,  during  violent  efforts  at  defsecation, 


XXl] 


LMPERFORATE   ANUS 


519 


felt  something  give  way,  and  discovered  faeces  in 
her  vagina.  The  recto-vaginal  wall  had  ruptured 
2  inches  from  the  anus.  During  labour  the  child's 
head  has  passed  into  the  rectum,  and  has  been 
delivered  per  anum. 

An  imperforate  anus  is  the  most  common  con- 
genital   defect    of    the    rectum.      This    condition 


7    SPECIMENS 


33  SPECIMENS 


.  7  SPECIMENS 


,  7  SPECIMENS 
SEPTUM 

NAL  CANAL 


Fig.  114. — Diagram  to  show  the  manner  in  which  the 
rectum  terminated  in  54  cases  of  imperforate  anus 
in  the  male. 

represents  an  arrest  of  development.  The  forma- 
tion of  the  anus  is  a  double  process  :  first  there  is 
an  ingrowth  from  the  perineum,  and  secondly  a 
downgrowth  from  the  bowel,  these  two  elements 
meeting  and  communicating  at  the  upper  end  of 
the  anal  depression.  In  many  cases  of  imperforate 
anus,  only  a  thin  anal  membrane  requires  to  be 


620  ABDOMEN   AND    PELVIS  [CHAP. 

broken  down  to  allow  the  free  passage  of  faeces; 
but  in  other  cases  the  defect  is  much  greater,  the 
anal  canal,  and  even  the  rectum,  being  completely 
wanting.  Not  infrequently  in  such  cases  the 
rectum  may  communicate  with  the  urethra  in 
the  male  or  with  the  vulval  cleft  in  the  female. 
This  communication  is  due  to  the  persistence  of 
an  embryonic  condition.  In  Fig.  114  is  given 
a  diagrammatic  representation  of  the  manner 
in  which  the  rectum  terminated  in  54  museum 
specimens  of  imperforate  anus.  In  more  than 
half  of  these  specimens — all  of  which  were  males 
— the  rectum  ended  at  the  lower  part  of  the 
prostate.  In  the  female  it  may  terminate  at 
any  point  of  the  vagina  or  open  in  the  vulval 
cleft.  The  proetodaeal  invagination  for  the  anal 
canal  may  be  incompletely  formed  or  absent, 
but  a  sphincter  is  always  present.* 

NERVES   OF   PELVIS  AND  PERINEUM 

The  pelvic  viscera  are  supplied  bv  the  pelvic 

Elexus  of  the  sympathetic.     This  is  joined  by  at 
;ast  three  spinal  nerves,  the  second,   third,   and 
fourth  sacral. 

It  is  well  known  that  in  certain  affections  of 
the  bladder,  rectum,  prostate,  etc.,  pain  is  felt 
along  the  perineum,  in  the  penis,  over  the  but- 
tock, and  down  the  thigh.  These  parts  are  sup- 
plied by  the  pudic  and  small  sciatic  nerves,  and 
the  reason  for  the  pain  is  explained  by  the  origin 
of  the  sensory  nerves  for  those  organs  from  the 
same  and  adjoining  segments  and  nerve  centres  of 
the  spinal  cord.  The  upper  part  of  the  rectum 
is  provided  with  but  little  sensation,  as  illus- 
trated by  the  passage  of  instruments,  by  the 
comparative  painlessness  of  malignant  and  other 
growths  high  up  in  the  bowel,  and  by  the  little 
inconvenience  felt  when  the  gut  is  distended  with 
hardened  faeces.  From  this  apathy  it  has  prob- 
ably happened  that,  in  the  self-administration  of 

*  See  Keith,  Brit.  Med.  Jmt-fn.,  Dec.,  1908. 


xxi]       PELVIC  AND   PERINEAL  NERVES        521 

enemata,  patients  have  thrust  the  tube  through 
the  rectum  into  the  peritoneal  cavity.  The  anal 
canal,  on  the  other  hand,  is  extremely  sensitive. 
Normally,  as  stated  above,  fullness  of  the  rectum 
excites  the  sensation  leading  to  defsecation.  If 
there  is  obstruction  or  distension,  combined  with 
spasm  of  the  muscular  coat,  severe  ill-defined 
pains  are  occasioned. 

The  nerve  relations  between  the  anus  and  the 
neck  of  the  bladder  are  very  intimate.  Painful 
affections  of  the  anus  often  cause  bladder  troubles, 
and  retention  of  urine  is  very  common  after 
operations  upon  piles.  Maladies,  on  the  other 
hand,  which  involve  the  bladder  neck  are  often 
associated  with  tenesmus  and  anal  discomfort. 
Their  relationship  to  common  functional  centres 
in  the  spinal  cord  is  maintained  by  the  pelvic 
plexus,  but  mainly  by  the  fourth  sacral  nerve. 
This  nerve  gives  special  branches  direct  to  the 
neck  of  the  bladder,  and  then  goes  to  supply 
the  muscles  of  the  anus  (the  sphincter  and 
levator)  and  the  integument  between  the  anus 
and  the  coccyx. 

The  mucous  membrane  of  the  urethra,  the 
muscles  of  the  penis,  and  the  greater  part  of 
the  skin  of  the  penis,  scrotum,  perineum,  and  anus, 
are  supplied,  from  the  second,  third,  and  fourth 
sacral  segments,  by  the  pudic  nerve.  Thus,  it 
will  be  understood  that  irritation  applied  to  the 
urethra  may  cause  erection  of  the  penis  (as  illus- 
trated by  chordee  in  gonorrhoea),  or  may  produce 
contraction  of  the  urethral  muscles  (as  seen  in 
some  forms  of  spasmodic  stricture).  The  disturb- 
ance caused  by  accumulated  secretion  beneath  the 
prepuce  in  young  children  may  provoke  great 
irritabilitv  of  the  organ,  and  it  is  well  known 
that  painful  affections  of  the  perineum  and  anus 
may  be  associated  with  priapism.  The  distribu- 
tion of  the  third  sacral  segment  in  the  perineum 
by;  means  of  the  perineal  branch  of  the  small 
sciatic  will  explain  the  pain  about  the  buttock 
and  down  the  back  of  the  thigh  that  is  often 
R* 


522  ABDOMEN  AND   PELVIS 

complained  of  during  the  growth  of  perinea! 
abscess  and  in  painful  affections  of  the  scrotum. 
This  nerve  crosses  just  in  front  of  the  tuber 
ischii,  and  may  be  so  pressed  upon  by  using  a 
hard  seat  as  to  cause  one-sided  neuralgia  of  the 
penis  and  scrotum.  It  is  also  in  close  connexion 
with  the  ischial  bursa,  and  neuralgia  of  the  same 
parts  has  been  met  with  in  cases  of  inflammation 
involving  that  structure. 

The  testicle  is  supplied  mainly  from  the  tenth 
dorsal  segment  by  the  spermatic  plexus.  The  kid- 
ney is  also  partly  supplied  from  the  same  segment. 
This  is  illustrated  by  the  pain  felt  in  the  renal 
region  during  neuralgia  of  the  testicle,  and  by  the 
pain  felt  in  the  testicle  and  the  vigorous  retraction 
of  that  organ  observed  in  certain  affections  of 
the  kidney,  such  as  in  acute  nephritis,  and  in  the 
passage  of  renal  calculi.  By  means  of  the  renal 
plexus  the  testicle  is  brought  into  direct  communi- 
cation with  the  semilunar  ganglia  and  the  solar 
plexus,  which  receives  some  of  the  terminal  fibres 
of  the  vagus.  This  communication  may  serve  to 
explain  the  great  collapse  often  noticed  in  sudden 
injuries  to  the  testicle,  and  especially  the  marked 
tendency  to  vomit  so  often  observed  in  such 
lesions.  ^  So  far  as  its  nerves  are  concerned,  the 
testicle  is  nearly  in  as  intimate  relation  with  the 
great  nerve-centre  of  the  abdomen  as  is  a  great 
part  of  the  small  intestine,  and  one  would  expect 
a  sudden  crush  of  the  testis  to  be  associated  with 
as  severe  general  symptoms  as  would  accompany 
a  sudden  nipping  of  the  ileum  in  a  rupture. 
Such  a  resemblance  in  symptoms  is  actually  to  be 
observed  in  practice. 


PART  V— THE  LOWER  EXTREMITY 

CHAPTER   XXII 
THE    REGION    OF    THE    HIP 

THIS  region  will  be  considered  under  the  follow- 
ing heads  :  — 

1.  The  buttocks. 

2.  The    region    of    the    femoral     (Scarpa's) 

triangle. 

3.  The   hip-joint,    with   the   upper   third  of 

the  femur. 

1.  THE  BUTTOCKS 

Surface  anatomy. — The  bony  points  about 
the  gluteal  region  can  be  well  made  out.  The 
crest  of  the  ilium  is  distinct,  as  is  also  the 
anterior  superior  spine.  The  posterior  superior 
spine  is  less  evident,  but  can  be  readily  felt  by 
following  the  crest  to  its  posterior  termination. 
This  spine  is  on  a  level  with  the  second  sacral 
spine,  and  is  placed  just  behind  the  centre  of  the 
sacro-iliac  articulation  (Fig.  115).  The  great  tro- 
chanter  is  a  conspicuous  landmark.  It  is  covered 
by  the  f  ascial  insertion  of  the  gluteus  maximus.  Its 
upper  border  is  on  a  level  with  the  centre  of  the 
hip- joint,  and  is  somewhat  obscured  by  the  tendon 
of  the  gluteus  medius  which  passes  over  it.  The 
comparatively  slight  prominence  of  the  trochanter 
523 


524  THE    LOWER    EXTREMITY          [CHAP 

in  the  living  subject,  as  compared  with  the  great 
projection  it  forms  in  the  skeleton,  depends 
upon  the  completeness  with  which  the  gluteus 
medius  and  minimus  fill  up  the  hollow  between 
the  trochanter  and  the  ilium.  When  these 
muscles  are  atrophied  the  process  becomes  very 
conspicuous.  In  fat  individuals  its  position  is 
indicated  by  a  slight  but  distinct  depression  over 
the  hip. 

If  a  line  be  drawn  from  the  anterior  superior 
spine  to  the  most  prominent  part  of  the  tuber 
ischii,  it  will  cross  the  centre  of  the  acetabulum, 
and  will  hit  the  top  of  the  trochanter.  This  line, 
known  as  Nelaton's  line,  is  frequently  made  use 
of  in  the  diagnosis  of  certain  injuries  about  the 
hip  (Fig.  115).  McCurdy  prefers  a  line  drawn 
from  the  pubic  spine  at  a  right  angle  to  the 
median  line  of  the  body;  if  the  femur  is  normal 
in  position  the  pubic  line  should  cross  at  or  just 
above  the  great  trochanter  (Fig.  116).  The  mid- 
point of  this  line  lies  in  front  of  the  lower 
part  of  the  femoral  head.  The  anterior  superior 
spine  or  crest  of  the  ilium  may  be  used  as  a  fixed 
point  from  which  to  estimate  the  degree  of  dis- 
placement of  the  great  trochanter. 

The  ischial  tuberosities  are  readily  felt.  They 
are  covered  by  the  fleshy  fibres  of  the  gluteus  maxi- 
mus when  the  hip  is  extended.  But  when  the  hip 
is  flexed,  the  processes  become  to  a  great  extent 
uncovered  by  that  muscle.  The  muscular  mass  of 
the  buttock  is  formed  by  the  gluteus  maximus  be- 
hind and  by  the  gluteus  medius  and  minimus  and 
tensor  fasciae  femoris  in  front.  The  last-named 
muscle  can  be  seen  when  in  action,  i.e.  when  the 
thigh  is  abducted  and  rotated  in. 

The  fold  of  the  buttock  crosses  the  oblio^uely- 
placed  lower  border  of  the  gluteus  maximus. 
When  the  hip  is  fully  extended,  as  in  the  erect 
posture,  the  buttocks  are  round  and  prominent, 
the -gluteal  fold  is  transverse  and  very  distinct. 
When  the  hip  is  a  little  flexed,  the  buttocks  be- 
come flattened,  the  gluteal  fold  becomes  oblique 


XXII] 


HIP  DISEASE 


525 


and  then  disappears.  Among  the  early  signs 
of  hip  disease  are  flattening  of  the  buttock  and 
loss  of  the  gluteal  fold.  These  signs  depend 
upon  the  flexion  of  the  hip,  which  is  practically 


PS.S 


A.SS. 


ACRO-/LIAC 

JOINT 


NlLATONS    LINE 


GREAT  TROCH, 


-  SMALL    TROCH. 


ISCHIAL 
TUBEROSITY 


Fig.  115. — Diagram    showing    the   line    used  by    Nelaton 

to    test     upward    displacement    of    the  femur,    and 

another   which    serves    to    indicate    the  position  for 
trephining  the  sacro-iliac  joint. 

A.S.S.,  Anterior  superior  spine  of  ilium ;   P.S.S.,  posterior  superior 
spine  of  ilium.    • 


526 


THE    LOWER    EXTREMITY 


[CHAP, 


constant  in  every  case  of  the  malady  before 
treatment.  Very  soon,  however,  in  all  cases  of 
disease  of  the  hip-joint,  and  also  in  many  cases 
of  true  sciatica,  reflex  wasting  of  the  gluteal 
musculature  sets  in. 


TIP  OF 

GREAT  TROCH 


ARCH 


M9 CURDYS 

on 
f»t/0O-TROCH. 

LINE: 


SMALL.   TROCH. 


Fig.  116. — Diagram  showing  that  the  pubic  spine  (tu- 
bercle) and  the  tip  of  the  great  trochanter  are  on  the 
same  horizontal  plane  (McCurdy's  line),  and  that  the 
lower  border  of  the  neck  of  the  femur  and  the  inner 
border  of  the  obturator  foramen  form  a  continuous 
arch  (Shenton's)  when  the  femur  has  its  normal 
relationships. 


xxn]  THE   BUTTOCK  527 

With  regard  to  the  vessels  and  nerves  of  the 
buttock,  if  a  line  be  drawn  from  the  posterior 
superior  spine  to  the  top  of  the  great  trochanter 
when  the  thigh  is  rotated  in,  a  point  at  the  junc- 
tion of  the  inner  with  the  middle  third  of  that 
line  will  correspond  to  the  superior  gluteal  artery 
as  it  emerges  from  the  sciatic  notch.  A  line 
drawn  from  the  posterior  superior  spine  to  the 
outer  part  of  the  tuber  ischii  crosses  both  the 
posterior  inferior  and  ischial  (sciatic)  spines 
(Fig.  117).  The  former  is  about  2  inches  and 
the  latter  about  4  inches  below  the  posterior 
superior  process.  The  sciatic  artery  reaches  the 
gluteal  region  at  a  spot  corresponding  to  the 
junction  of  the  middle  with  the  lower  third  of 
this  line.  The  position  of  the  pudic  (pudendal) 
artery  as  regards  the  buttock  is  not  _  difficult 
to  indicate,  since  it  crosses  over  the  ischial  spine 
in  passing  from  the  great  to  the  small  sacro- 
sciatic  foramen.  The  sciatic  nerve  is  most  easily 
found  as  it  escapes  from  beneath  the  gluteus  maxi- 
mus.  When  the  thigh  is  rotated  outwards,  so  that 
the  great  trochanter  approaches  the  ischial  tuber- 
osity,  the  nerve  lies  midway  between  these  two 
bony  points,  but  in  the  unrotated  position  ^it  is 
found  at  the  junction  of  the  inner  and  middle 
thirds  of  a  line  joining  them. 

The  skin  over  the  buttock  is  thick  and  coarse, 
and  is  frequently  the  seat  of  boils.  The  suto- 
cutaiieous  fascia  is  lax,  and  contains  a  large 
quantity  of  fat.  It  is  to  this  fat  rather  than 
to  muscular  development  that  the  buttock  owes 
its  roundness  and  prominence.  The  enormous 
buttocks  of  the  so-called  "Hottentot  Venus," 
whose  model  is  in  many  museums,  depend  for 
their  unusual  dimensions  upon  the  greatly  in- 
creased subcutaneous  fat.  The  amount  of  adipose 
tissue  normally  in  the  part  renders  the  buttock 
a  favourite  place  for  lipomata.  The  laxity  of  the 
superficial  fascia  permits  large  effusions,  botb  of 
blood  and  pus,  to  take  place  in  the  gluteal  region, 
and  ecchymoses  of  the  buttock  can  probably  reach 


528  THE    LOWER    EXTREMITY  [CHAP. 

a  greater  magnitude  in  this  district  than  is 
possible  elsewhere. 

The  deep  fascia  of  the  buttock,  a  part  of 
the  fascia  lata  of  the  thigh,  is  a  structure  of  much 
importance.  TMS  dense  membrane  is  attached 
above  to  the  iliac  crest,  and  to  the  sacrum  and 
coccyx.  Descending  in  front  over  the  gluteus 
medius,  it  splits  on  reaching  the  interior  edge  of 
the  gluteus  maximus  into  two  layers,  one  of  which 
passes  superficially  and  the  other  deeply  to  the 
muscle.  The  gluteus  maximus  is  thus  enclosed, 
like  the  meat  in  a  sandwich,  between  two  layers 
of  fascia,  and  the  two  lesser  gluteal  muscles  are 
bound  down  within  an  osseo-aponeurotic  space, 
which  is  firmly  closed  above,  and  only  open  below 
towards  the  thigh  and  internally  at  the  sciatic 
foramina.  Extravasations  of  blood  may  take 
place  beneath  this  fascia  without  any  discolora- 
tion of  the  skin  to  indicate  the  fact,  the  blood 
being  unable  to  reach  the  surface  through  the 
dense  membrane.  Such  extravasations  may  be 
long  pent  up,  and,  as  they  fluctuate,  may  be 
mistaken  for  abscess. 

Deep  inflammations,  beneath  this  fascia,  and 
especially  when  beneath  the  gluteus  medius,  may 
be  associated  with  much  pain,  owing  to  the  cir- 
cumstance that  the  inflammatory  effusions  will  be 
pent  up  between  a  wall  of  bone  on  one  side  and 
a  wall  of  dense  fascia  and  stout  muscle  on  the 
other.  Abscesses  so  pent  up  may  travel  for  a 
considerable  distance  down  the  thigh  before  they 
reach  the  surface,  and  Farabeuf  relates  a  case 
where  a  gluteal  abscess  travelled  to  the  ankle 
before  it  broke.  In  other  circumstances  the  gluteal 
abscess  may  make  its  way  into  the  pelvis  through 
the  sciatic  foramina,  or  a  pelvic  abscess  may 
escape  through  one  of  these  foramina  and  appear 
as  a  deep  abscess  of  the  buttock. 

The  thickened  part  of  the  fascia  lata  that  runs 
down  on  the  outer  side  of  the  limb,  between  the 
crest  of  the  ilium  above  and  the  outer  tuberosity 
of  the  tibia  and  head  of  the  fibula  below,  is 


xxn]  THE   BUTTOCK  529 

known  as  the  ilio-tibial  band.  This  band  is  tightly 
stretched  across  the  gap  between  the  iliac  crest 
and  the  great  trochanter,  and,  if  pressure  be  made 
with  the  fingers  between  these  two  points,  the  re- 
sistance of  this  part  of  the  fascia  can  be  appreci- 
ated. It  is  obvious  that  in  fracture  of  the  neck 
of  the  femur,  when  the  great  trochanter  is  made 
to  approach  nearer  to  the  crest,  this  band  will 
become-  relaxed — an  observation  which  may  be 
of  value  in  the  diagnosis  of  fractures  of  the 
femoral  neck. 

The  lower  free  edge  of  the  gluteus  maximus 
is  oblique,  and  ends  some  way  below  the  transverse 
line  of  the  fold  of  the  buttock  (Fig.  117).  It  would 
appear  that  even  this  great  muscle  may  be  rup- 
tured by  violence.  Thus  a  case  has  been  reported 
of  a  robust  man  aged  63,  who,  while  trying  to 
lift  a  heavy  cart  when  in  a  crouching  position, 
felt  something  give  way  in  his  buttock,  and 
heard  a  snap.  He  fell,  and  was  carried  home, 
when  it  was  found  that  the  great  gluteal  muscle 
was  ruptured  near  the  junction  of  the  muscle  with 
its  tendon. 

At  least  three  fonrsae  exist  over  the  great 
trochanter,  separating  that  process  from  the  three 
gluteal  muscles  respectively.  The  most  extensive  is 
that  between  the  insertion  of  the  gluteus  maximus 
into  the  ilio-tibial  band  and  the  outer  surface  of 
the  great  trochanter.  The  bursa  allows  the  great 
trochanter  to  move  freely  beneath  the  muscle 
during  rotation  of  the  thigh.  When  this  sac  is 
inflamed,  much  difficulty  is  experienced  in  moving 
the  limb,  and  the  thigh  is  generally  kept  flexed 
and  adducted.  This  position  means  absolute  rest 
from  movement  on  the  part  of  the  gluteal  muscles, 
which,  when  acting,  would  extend  and  abduct 
the  limb,  and  bring  pressure  to  bear  upon  the 
tender  bursa. 

There  is  a  bursa  over  the  ischial  tuberosity 
that  is  often  inflamed  in  those  whose  employments 
involve  much  sitting,,  the  bursa  being  directly 
pressed  upon  in  that  position.  This  sac  is  the 


530  THE    LOWER    EXTREMITY  [CHAP. 

anatomical  basis  of  the  disease  known  in  older 
text-books  as  "weaver's  bottom  "  or  "lighter- 
man's bottom."  When  enlarged  this  bursa  may 
press  upon  the  inferior  pudendal  nerve  (perineal 
branch  of  the  posterior  femoral  cutaneous). 

Arteries  and  nerves  of  tlie  buttock.  — 
The  superior  gluteal  artery  is  about  the  same  size 
as  the  ulnar,  and  the  sciatic  (inferior  gluteal) 
as  the  lingual.  The  former  vessel  may  sometimes 
be  of  much  greater  magnitude,  and  has  led, 
when  wounded,  to  rapid  death  from  haemorrhage. 
Wounds  of  the  gluteal  vessels  will  probably  in- 
volve only  the  branches  of  the  artery,  since  the 
greater  part  of  the  main  trunk  is  situate  within 
the  pelvis.  Gluteal  aneurysms  are  not  very 
uncommon,  and  with  regard  to  the  treatment  of 
these  tumours  it  may  be  noted  that  the  gluteal 
artery,  or,  better,  the  internal  iliac  (hypogastric) 
trunk,  can  be  compressed  through  the  rectum. 
Both  the  gluteal  and  sciatic  arteries  have  been 
ligatured  in  the  buttock,  through  incisions  made 
directly  over  the  course  of  the  vessels.  In  rare 
cases  the  companion  artery  of  the  sciatic  nerve 
may  assume  the  size  and  functions  of  the  femoral 
artery. 

The  sciatic  nerve  is  a  continuation  down- 
wards of  the  main  part  of  the  sacral  plexus 
(Fig.  117).  It  is  in  this  nerve  that  the  form  of 
neuralgia  known  as  sciatica  is  located.  A  reference 
to  the  immediate  relations  of  the  nerve  will  show 
that  it  may  readily  be  exposed  to  many  external 
influences.  Thus,  in  the  pelvis  it  may  be  pressed 
upon  by  various  forms  of  pelvic  tumour,  and 
sciatica  be  produced  in  consequence.  Accumula- 
tion of  faeces  within  the  rectum  may  press  on 
this  nerve  and  thus  cause  neuralgia.  It  is  said 
to  have  been  injured  also  by  the  pressure  of  the 
foetal  head  during  tedious  labours,  and  to  be 
affected  by  violent  movements  of  the  hip,  a  cir- 
cumstance readily  understood  if  the  close  relation 
of  the  nerve  to  the  hip-joint  be  borne  in  mind. 
The  nerve  is  also  near  enough  to  the  surface 


XXII] 


SCIATIC  NERVE 


531 


to  be   influenced    by   external    cold,    and    to    this 
influence  many  forms  of  sciatica  are  ascribed. 

Nerve  stretching  and  injecting.— The  swat'ic 
nerve  has  been  frequently  cut  down  upon  and 
stretched  for  the  relief  of  certain  nervous  affec- 
tions of  the  limb.  In  connexion  with  this 


POST.  SUP.  SPINE 


LFSSER  SACRO-SCIATIO  LIQ 
GREAT  SACRO  SCIATIC  LIG. 


ISCHIAL  TUBER 


GLUTEAL  FOLD 


GREAT  SCIATIC  N. 


Fig.  117. — Formation  and  relationships  of  the  upper  part 
of  the  sciatic  nerve. 

procedure  it  is  important  to  know  how  great 
an  amount  of  traction  may  be  brought  to  bear 
upon  this  and  other  nerves  without  the  cord 
giving  way.  Trombetta,  who  has  paid  much 
attention  to  the  breaking -point  of  nerves,  gives  the 
following  weights  as  those  required  to  break  the 
undermentioned  nerves:  — 

Great  sciatic,  183  Ib. 

Internal  popliteal  (til)ial),  114  11). 

Anterior  crural  (femoral),  83  Ib. 

Median,  83  Ib. 

Ulnar  and  radial,  59  Ib. 

Brachial  plexus  in  the  neck,  48-63  Ib. 

Brachial  plexus  in  the  axilla,  35-81  Ib. 


532  THE    LOWER    EXTREMITY          [CHAP. 

.The  sciatic  nerve  may  be  stretched  by  flex- 
ing the  extended  lower  extremity  of  the  belly. 
This  measure  has  served  to  cure  certain  cases 
of  sciatica.  For  the  hypodermic  injection  of  the 
sciatic  nerve  to  relieve  sciatica,  the  needle  is 
inserted  so  as  to  penetrate  the  nerve  as  it  lies 
on  the  bone  below  the  great  sacro-sciatic  (sciatic) 
notch.  This  point  is  best  found  by  a  guide-line 
drawn  from  the  posterior  superior  iliac  spine  to 
the  ischial  tuberosity.  If  the  point  of  the  needle 
be  inserted  ^  an  inch  externally  to  the  junction 
of  the  middle  and  lower  thirds  of  this  line,  it 
lies  directly  over  the  nerve  (Fig.  117).  The  nerve 
is  here  covered  by  the  gluteus  maximus,  and  lies 
on  the  ischium  between  the  pyriformis  above  and 
the  obturator  internus  below. 

The  skin  of  the  buttock  is  well  supplied  with 
nerves,  and  tactile  sensibility  is  almost  as  acute 
in  this  part  as  it  is  over  the  back  of  the  hand, 
while  it  is  more  acute  than  is  like  sensibility 
in  such  parts  as  the  back  of  the  neck,  the  middle 
of  the  thigh,  and  the  middle  of  the  back.  The 
sensation  of  the  gluteal  integument  is  derived 
from  a  number  of  different  nerves,  and  it  may 
possibly  interest  a  schoolboy  who  has  been  re- 
cently birched  to  know  that  the  painful  sensations 
reached  his  sensorium  through  some  or  all  of  the 
following  nerves :  Offsets  of  the  posterior  branches 
of  the  lumbar  nerves,  some  branches  of  the  sacral 
nerves,  the  lateral  cutaneous  branch  of  the  last 
dorsal  nerve,  the  iliac  (lateral)  branch  of  the  ilio- 
hypogastric  nerve,  offsets  of  the  external  (lateral) 
cutaneous  nerve,  and  large  branches  of  the  small 
sciatic.  These  nerves  are  derived  from  four  spinal 
segments — the  twelfth  dorsal,  first  lumbar,  second 
and  third  sacral  (Fig.  149,  p.  643).  The  second 
and  third  sacral  also  supply  the  sexual  organs, 
hence  the  physiological  effects  which  may  follow 
application  of  punishment  to  this  part,  as  in 
the  celebrated  case  of  J.  J.  Rousseau. 

It  should  be  remembered  that  the  pelvic  vis- 
cera can  be  readily  reached  through  the  sciatic 


xxn]  FEMORAL  TRIANGLE  533 

foramina  from  the  buttock.  A  case  was  admitted 
to  the  London  Hospital  of  a  man  who  had  an 
apparently  insignificant  stab  of  the  buttock.  He 
died  in  a  few  days  of  acute  peritonitis,  and 
the  autopsy  showed  that  the  dagger  had  passed 
through  the  great  sacro-sciatic  foramen,  had 
entered  the  bladder  and  allowed  urine  to  escape 
into  the  peritoneal  cavity.  In  the  Great  War 
many  of  the  worst  abdominal  injuries  were  those 
in  which  the  wounds  of  entry  were  situated  in 
the  region  of  the  buttock.  The  rectum,  too,  has 
been  damaged  in  injuries  to  the  buttock;  and 
Anger  records  a  case  of  an  artificial  anus  situate 
upon  the  buttock  which  had  followed  a  gunshot 
wound  that,  after  involving  the  buttock,  had 
opened  up  the  caecum.  It  is  by  this  route  that 
Kraske's  operation  for  resection  of  the  rectum 
is  performed,  and  also  Rigby's  operation  on  the 
ureter. 

2.  THE  REGION  OF  THE  FEMORAL  (SCARPA'S) 
TRIANGLE 

Surface  anatomy.— The  most  important  land- 
marks in  the  region  of  the  groin,  the  anterior 
superior  iliac  spine,  the  spine  (tubercle)  of  the 
pubes,  and  the  inguinal  (Poupart's)  ligament,  are 
readily  made  out.  To  the  two  spines  reference 
has  already  been  made  (p.  524).  The  inguinal 
ligament  follows  a  curved  line,  with  its  con- 
vexity downwards,  drawn  between  these  two  pro- 
jections. It  can  be  felt  in  even  stout  persons, 
its  inner  half  more  distinctly  than  its  outer, 
and  even  in  very  fat  individuals  its  position 
is  indicated  by  a  slight  furrow.  Owing  to  its 
attachment  to  the  fascia  lata  the  ligament  is 
relaxed  and  rendered  less  distinct  when  the  thigh 
is  flexed  and  adducted,  or  when  it  is  rotated  in. 
The  mid-point  of  a  line  joining  the  pubic  with 
the  anterior  superior  spine  lies  over  the  head 
of  the  femur  and  hip- joint.  In  this  position  a 
crease  is  often  to  be  seen  crossing  the  groin. 

The  sartorius  muscle  is  brought  into  view  when 


534  THE    LOWER    EXTREMITY  [CHAP. 

the  leg  is  raised  across  the  opposite  knee,  and  the 
adductor  longus  is  rendered  distinct  when  the 
thigh  is  abducted  and  the^  subject's  attempts 
to  adduct  the  limb  are  resisted.  Even  in  the 
obese  the  edge  of  this  muscle  can  be  felt  when 
it  is  in  vigorous  action,  and  the  fingers  can 
follow  its  border  up  to  the  very  origin  of  the 
muscle,  just  below  the  pubic  spine. 

The  lymphatic  glands  in  this  region  can  some- 
times be  felt  beneath  the  skin,  especially  in  thin 
children.  The  femoral  ring  lies  behind  the  inguinal 
ligament  1  inch  externally  to  the  pubic  spine 
(Fig.  81,  p.  367).  The  position  of  the  saphenous 
opening  (fossa  ovalis)  is  sometimes  indicated  by 
a  slight  depression  in  the  integuments.  It  lies 
just  below  the  inguinal  ligament,  and  its  centre, 
is  about  1^  inches  below  and  external  to  the 
pubic  spine.  In  thin  subjects  the  long  saphen- 
ous vein  can  often  be  made  out,  passing  to  the 
saphenous  opening. 

If  a  line  be  drawn  from  the  femoral  point 
(Fig.  81,  p.  367)  to  the  tubercle  for  the  adductor 
magnus,  on  the  inner  (medial)  condyle  of  the 
femur,  when  the  thigh  is  slightly  flexed  and 
abducted,  it  will  correspond  in  the  upper  two- 
thirds  of  its  extent  to  the  position  of  the  femoral 
artery.  Just  below  the  inguinal  ligament  the 
femoral  vein  lies  to  the  inner  side  of  the  artery, 
while  the  anterior  crural  (femoral)  nerve  runs 
about  J  of  an  inch  to  its  outer  side.  The  pro- 
funda  femoris  arises  about  1|  inches  below  the 
inguinal  ligament,  and  the  internal  and  external 
circumflex  vessels  come  off  about  2  inches  below 
that  structure. 

The  skin  over  the  femoral  (Scarpa's)  triangle  is, 
unlike  that  of  the  buttock,  comparatively  thin  and 
fine.  The  looseness  of  its  attachment,  also,  to  the 
parts  immediately  beneath  permits  it  to  be  greatly 
stretched,  as  is  seen  in  cases  of  large  femoral 
hernise,  and  in  certain  inguinal  tumours  of  large 
size.  It  may  even  give  way  under  severe  traction, 
as  occurred  in  a  case  reported  by  Berne,  The 


XXH]  FEMORAL  TRIANGLE  535 

patient  in  this  case  was  a  child  aged  11,  the  sub- 
ject of  hip  disease.  The  thighs  were  flexed  upon 
the  abdomen,  and,  forcible  extension  being  ap- 
plied to  relieve  the  deformity,  the  skin  gave  way 
just  below  the  groin,  and  separated  to  the  extent 
of  some  2^  inches.  Contracting  scars  in  the  region 
of  the  groin  may  produce  a  permanent  flexing  of 
the  hip,  and  this  result  is  not  uncommon  after 
deep  and  severe  burns  in  this  neighbourhood.  It 
may  at  the  same  time  be  noted  that  horizontal 
wounds  about  the  groin  can  be  well  adjusted  by 
a  slight  flexion  of  the  thigh. 

Instances  are  recorded  where  a  supernumerary 
mammary  gland,  provided  with  a  proper  nipple, 
has  been  found  located  in  the  groin.  Jessieu 
relates  the  case  of  a  female  who  had  a  breast  so 
placed,  and  who  suckled  her  child  from  this 
part  (see  p.  223).  In  a  few  cases  the  testicle,  in- 
stead of  descending  into  the  scrotum,  has  escaped 
through  the  femoral  canal,  and  made  its  ap- 
pearance in  the  femoral  triangle.  It  has  even 
mounted  up  over  the  inguinal  ligament  after  the 
manner  of  a  femoral  hernia,  being,  probably  urged 
in  that  direction  by  the  movements  of  the  limb. 

The  superficial  fascia  in  this  region  is  not 
very  dense,  and  has  little  or  no  influence  upon 
the  progress  of  a  superficial  abscess.  This  fact 
receives  extensive  illustration,  since  the  glands  in 
Scarpa's  ^triangle  frequently  <  suppurate,  and  yet 
the  pus  in  the  great  majority  of  cases  readily 
reaches  the  surface  in  spite  of  the  circumstance 
that  the  denser  layer  of  the  superficial  fascia  (for 
in  this  region  it  is  divided  into  two  layers)  covers 
in  those  glands,  and  should  hinder  the  progress 
of  pus  towards  the  surface.  Although  the  sub- 
cutaneous fat  is  not  peculiarly  plentiful  in  this 
region,  yet  the  femoral  triangle  is  a  favourite 
spot  for  lipomata. 

The  fascia  lata  completely  invests  the  limb, 
being,  so  far  as  the  front  of  the  thigh  is  con- 
cerned, attached  above  to  the  inguinal  ligament,  to 
the  body  and  ramus  of  the  pubes,  and  the  ramus 


536  THE    LOWER    EXTREMITY  [CHAP. 

of  the  ischium.  Its  integrity  is  interrupted  only 
by  the  saphenous  opening.  This  fascia  exercises 
some  influence  upon  deep  abscesses  and  deep 
growths.  Thus  a  psoas  abscess  reaches  the  thigh 
by  following  the  substance  of  the  psoas  muscle, 
and  finds  itself,  when  it  arrives  at  the  femoral 
triangle,  under  the  fascia  lata.  In  a  great  number 
•of  cases  it  points  where  the  psoas  muscle  ends, 
but  in  other  and  less  frequent  instances  its  pro- 
gress is  decidedly  influenced  by  the  fascia  lata, 
and  it  moves  down  the  limb.  Thus  guided,  a 
psoas  abscess  has  pointed  low  down  in  the  thigh, 
and  even  at  the  knee,  and  Erichsen  reports  a  case 
where  such  an  abscess  (commencing,  as  it  did,  in 
the  dorsal  spine)  was  ultimately  opened  by  the 
side  of  the  tendo  Achillis  (calcaneus). 

Muscles* — The  ilio-psoas  muscle,  which  is 
stretched,  as  it  were,  over  the  front  of  the  hip- 
joint,  and  participates  in  many  of  the  movements 
of  that  joint,  is  peculiarly  liable  to  be  sprained  in 
violent  exercises.  Between  this  muscle  and  the  thin- 
nest part  of  the  hip  capsule  is  a  bursa,  which  not 
infrequently^  communicates  with  the  joint.  When 
chronically  inflamed,  this  bursa  may  form  a  large 
tumour  on  the  front  of  the  thigh  that  may,  ac- 
cording to  Nancrede,  attain  the  size  of  a  child's 
head.  To  relieve  this  bursa  from  pressure  when 
inflamed,  the  thigh  always  becomes  flexed,  and  a 
train  of  symptoms  is  produced  not  unlike  those 
of  hip  disease.  The  ilio-psoas  muscles  also  act 
on  the  intervertebral  joints  of  the  lumbar  region 
of  the  spine  and  on  the  sacro-iliac  joints.  Hence, 
disease  of  any  of  these  joints  will  throw  the 
ilio-psoas  into  an  irritable  and  contracted  con- 
dition. Indeed,  no  muscles  in  the  body  have 
more  extensive  or  more  important  clinical  re- 
lations than  have  the  ilio-psoas;  if  the  kidneys, 
ureters,  caecum,  appendix,  sigmoid  colon,  pancreas, 
iliac  chain  of  lymphatic  glands,  or  nerves  of 
the  lumbar  plexus  suffer  from  diseased  conditions, 
then  movements  in  which  the  ilio-psoas  muscles 
are  involved  will  be  accompanied  by  pain. 


xxn]  FEMORAL  ARTERY  537 

The  sartorius  is  a  muscle  which,  from  its  length, 
peculiar  action,  etc.,  one  would  hardly  expect  to 
find  ruptured  from  violence,  yet  in  the  Musee 
Dupuytren  there  is  a  specimen  of  such  a  rupture, 
about  the  middle  of  the  muscle,  united  by  fibrous 
tissue.  The  adductor  muscles,  and  especially  the 
adductor  longus,  are  frequently  sprained,  or  even 
partially  ruptured,  during  horse  exercise,  the  grip 
of  the  saddle  being  for  the  most  part  maintained 
by  theml.  "Rider's  sprains,"  as  such  accidents 
are  called,  usually  involve  the  muscles  close  to 
their  pelvic  attachments.  Much  blood  is  often 
effused  when  the  fibres  are  ruptured,  and  such 
effusion  may  become  so  dense  and  fibrinous  as  to 
form  a  mass  that  has  been  mistaken  for  a  detached 
piece  of  the  pubes  (Sir  Henry  Morris).  The  term 
"  rider's  bone "  refers  to  an  ossification  of  the 
upper  tendon  of  the  adductor  longus  or  magnus, 
following  a  sprain  or  partial  rupture.  Cases  are 
reported  where  the  piece  of  bone  in  the  tendon 
was  3  an  inch,  2  inches,  and  even  3  inches  long. 
It  occasionally  happens  in  strains  and  sudden 
exertions  that  the  insertion  of  a  muscle,  or  of  part 
of  a  muscle,  to  the  femur  is  partly  torn  away, 
bringing  with  it  a  piece  of  periosteum.  The  result 
is  that  new  bone  is  thrown  out  at  the  site  of  the 
rupture,  forming  a  tumour-like  mass  (Godlee). 

Blood-vessels. — The  femoral  artery  occupies 
so  superficial  a  position  in  the  femoral  triangle 
that  it  is  not  infrequently  wounded.  The  vessel  also 
has  been  opened  up  by  cancerous  and  phagedsenic 
ulcerations  of  this  part,  the  occurrence  leading  to 
fatal  hemorrhage.  Pressure  is  most  conveniently 
applied  to  the  artery  at  a  spot  immediately  below 
the  inguinal  ligament,  and  should  be  directed 
backwards,  so  as  to  compress  the  vessel  against 
the  pubes  and  adjacent  parts  of  the  hip  capsule. 
Lower^  down,  compression  should  be  applied  in  a 
direction  backwards  and  outwards,  so  as  to  bring 
the  artery  against  the  shaft  of  the  femur,  which 
lies  at  some  distance  to  its  outer  side.  Pres- 
sure rudely  applied  by  a  tourniquet  may  cause 


538  THE    LOWER    EXTREMITY          [CHAP. 

phlebitis  by  damaging  the  vein,  or  neuralgia  by 
contusing  the  anterior  crural  (femoral)  nerve. 

From  the  proximity  of  the  artery  and  vein, 
it  happens  that  arterio-venous  aneurysms  follow- 
ing wounds  have  been  met  with  in  this  situa- 
tion. Aneurysm  is  frequent  in  the  common 
femoral,  and  many  reasons  can  be  given  why  that 
vessel  should  be  attacked.  It  is  just  about  to 
bifurcate  into  two  large  trunks,  its  superficial 
position  exposes  it  to  injury,  it  is  greatly  influ- 
enced by  the  movements  of  the  hip,  and  its  coat 
may,  if  diseased,  be  damaged  by  those  movements, 
if  excessive. 

Phlebitis  of  the  femoral  vein  has  in  many  cases 
followed  contusion  of  the  vessel  in  its  upper  or 
more  superficial  part,  and  a  like  result  has  even 
followed  from  violent  flexion  of  the  thigh.  The 
long  (great)  saphenous  vein  is  often  varicose. 
The  saphenous  veins  lie  outside  the  fascia  lata, 
and  therefore  derive  no  support  from  it.  In 
muscular  exertions  the  pressure  in  the  veins  may 
be  greatly  raised,  and  then  the  muscular  coats 
of  the  saphenous  veins  have  to  bear  unaided  a 
considerable  burden.  If  that  burden  is  long  con- 
tinued the  muscular  coats  give  way  and  a  varicose 
condition  results. 

Nerves. — The  anterior  crural  or  femoral  nerve 
lies  on  the  ilio-psoas  muscle,  and  it  is  said  that 
neuralgia,  and  even  paralysis  of  the  nerve,  may 
follow  upon  inflammation  of  that  muscle  and 
upon  psoas  abscess.  The  superficial  position  of 
the  trunk  exposes  it  to  injury.  The  genito=crural 
nerve  (the  nerve  that  supplies  the  cremaster 
muscle)  gives  a  sensory  filament  to  the  integu- 
ment of  the  thigh  in  the  femoral  triangle.  Irri- 
tation of  the  skin  over  the  seat  of  this  nerve, 
which  is  placed  just  to  the  outer  side  of  the 
femoral  artery,  will  cause,  in  children,  a  sudden 
retraction  of  the  testicle.  The  same  result  is  often 
seen  in  adults,  also,  on  more  severe  stimulation. 
In  this  manner  the  condition  of  the  second  lumbar 
segment  of  the  spinal  cord  may  be  tested. 


xxn]  INGUINAL   GLANDS  539 

The  lymphatic  glands  in  this  region  are 
numerous,  arid,  as  they  are  frequently  the  seat  of 
abscess,  it  is  important  to  know  whence  they 
derive  their  afferent  vessels.  They  are  divided 
into  a  superficial  and  a  deep  set.  The  superficial 
set,  averaging  from  ten  to  fifteen  glands,  is  ar- 
ranged in  two  groups,  one  parallel  and  close  to 
the  inguinal  ligament  (the  horizontal  series),  the 
other  parallel  and  close  to  the  long  saphenous  vein 
(the  vertical  series).  The  deep  set,  about  four  in 
number,  are  placed  along  the  femoral  vein,  and 
reach  the  femoral  canal. 

The  inguinal  glands  receive  the  following  lym- 
phatics :— 

Superficial  vessels  of  lower  limb  =  vertical  set 
of  superficial  glands. 

Superficial  vessels  of  lower  half  of  abdomen  = 
middle  glands  of  horizontal  set. 

Superficial  vessels  from  outer  surface  of  but- 
tock =  external  glands  of  horizontal  set. 

From  inner  surface  of  buttock  =  internal 
glands  of  horizontal  set.  (A  few  of  these  vessels 
go  to  the  vertical  glands.) 

Superficial  vessels  from  external  genitals  =»• 
horizontal  glands  (some  few  going  to  vertical  set). 

Superficial  vessels  of  perineum  and  anus  = 
vertical  set. 

Deep  lymphatics  of  lower  limb  =  deep  set  of 
glands." 

The  lymphatics  which  accompany  the  obturator, 
gluteal,  and  sciatic  arteries  and  the  deep  vessels 
of  the  penis  pass  to  the  pelvis  and  have  no  con- 
nexion with  the  inguinal  glands.'  The  only  super- 
ficial lymphatics  of  the  lower  extremity  which  do 
not  pass  direct  to  the  inguinal  glands  are  those 
that  drain  the  outer  side  of  the  ankle  and  pos- 
terior aspect  of  the  leg.  The  vessels  from  these 
areas  accompany  the  short  (small)  saphenous  vein 
and  end  in  the  popliteal  glands;  the  efferent 
vessels  from  these  glands  pass  to  the  deep  in- 
guinal set. 

One  of  the  deep  glands  lies  in  the  femoral  canal 


540  THE    LOWER    EXTREMITY          [CHAP. 

and  upon  the  septum  femorale.  Being  surrounded 
by  dense  structures,  it  is  apt  to  cause  great  dis- 
tress when  inflamed  and  great  pain  when  the  hip 
is  moved.  In  some  cases,  by  reflex  disturbance, 
it  has  produced  symptoms  akin  to  those  of 
strangulated  hernia.  Some  branches  of  the  an- 
terior crural  (femoral)  nerve  lie  over  the  inguinal 
lymph-glands,  and  Sir  B.  Brodie  reports  a  case 
in  which  these  branches  were  stretched  over  two 
enlarged  glands,  like  strings  of  a  violin  over 
its  bridge,  so  that  violent  pains  and  convulsive 
movements  were  set  up  in  the  limb. 

The  efferent  vessels  from  the  inguinal  glands 
pass  through  a  chain  of  lymphatic  glands  stretch- 
ing along  the  course  of  the  external  and  common 
iliac  vessels.  Three  of  these  glands  lie  imme- 
diately above  the  inguinal  ligament.  The  efferent 
vessels  of  the  internal  iliac  group  of  glands,  into 
which  the  pelvic  lymphatics  drain,  join  the 
chain  along  the  common  iliac  vessels.  The  lumbar 
glands  receive  the  lymph  from  the  iliac  groups 
and  pass  it  on  by  the  right  and  left  lumbar  trunks 
to  the  cisterna  chyli. 

Elephantiasis  Arabum  is  more  common  in  the 
lower  limb  than  in  any  other  part,  and  leads  to  an 
enormous  increase  in  the  size  of  the  extremity 
(Cochin  or  Barbadoes  leg).  Its  pathology  is  in- 
timately concerned  with  the  inguinal  lymphatics. 
The  lymphatics  are  obstructed  by  the  larvae  of  a 
small  threadworm,  Filaria,  sanguinis  hominis.  The 
lymph-vessels  and  lymph-spaces  in  the  connective 
tissue  become  greatly  distended,  and  the  elements 
of  the  connective  tissue  hypertrophied. 

3.    THE  HIP-JOINT 

The  hip-joint  is  of  considerable  strength  (Fig. 
118),  not  only  on  account  of  the  shape  of  the 
articulating  bones,  which  permits  of  a  good  ball- 
and-socket  joint  being  formed,  but  also  because  of 
the  powerful  ligaments  that  connect  them  and  the 
muscular  bands  that  directly  support  the  capsule. 
These  advantages,  however,  are  to  some  extent 


XXII] 


THE   HIP-JOINT 


541 


counterbalanced  by  the  immense  leverage  that  can 
be  brought  to  bear  upon  the  femur,  and  the 
numerous  strains  and  injuries  to  which  the  joint 
is  subjected,  as  the  sole  connecting  link  between 
the  trunk  and  the  lower  limb. 


Fig.  118.— Vertical  section  of  the  upper  third  of  the  thigh, 
showing  the  structures  in  relationship  with  the  hip- 
joint.  (After  Braune. ) 

Muscles. — 1,  Psoas ;  2,  iliacus  ;  3,  glutens  medius ;  4,  gluteus  minimus  ; 
5,  obturator  internus  ;  6,  obturator  externus  ;  7.  ilio-psoas  ;  8,  pec- 
tineus  ;  9,  adductor  magnus  ;  10,  adductor  brevis  ;  11,  gracilis  ; 
12,  adductor  longus  ;  13,  vastus  internus  ;  14,  vastus  externus. 
a.  Anterior  crural  nerve  ;  b,  external  iliac  artery;  c,  external  iliac 
vein  ;  d,  obturator  nerve ;  e,  obturator  artery ;  /,  branches  of 
obturator  vessels  to  hip-joint ;  g,  internal  circumflex  vessels  ; 
h,  deep  femoral  vessels  ;  i,  bt  anch  of  external  circumflex  : .;',  bursa 
over  great  trochanter ;  k,  reflections  of  capsule  to  neck  of  femur  ; 
m,  ascending  rarnus  of  pubes  ;  n,  peritoneum  ;  o,  iliac  fascia. 


542  THE    LOWER    EXTREMITY          [CHAP. 

The  aretabiiliim  is  divided  into  an  articular 
and  a  non-articular  part.  The-  former  is  of 
horseshoe  shape,  and  varies  from  1  inch  to  |  an 
inch  in  width.  The  bone  immediately  above  the 
articular  area  is  very  dense,  and  through  it  is 
transmitted  the  superincumbent  weight  of  the 
trunk.  The  non-articular  part  corresponds  to  the 
area  enclosed  by  the  horseshoe,  and  is  made  up 
of  very  thin  bone.  It  is,  however,  rarely  frac- 
tured by  any  violence  that  may  drive  the  femur  up 
against  the  pelvic  bones,  since  no  ordinary  force 
can  bring  the  head  of  the  thigh-bone  in  contact 
with  this  segment  of  the  os  innominatum. 

Pelvic  abscesses  sometimes  make  their  way  into 
the  hip-joint  through  the  non-articular  part  of  the 
acetabulum,  and  an  abscess  in  the  hip-joint  may 
reach  the  pelvis  by  the  same  route.  But  both 
such  circumstances  are  rare.  In  some  cases  of  de- 
structive hip  disease  the  acetabulum  may  separate 
into  its  three  component  parts.  Up  to  the  age 
of  puberty  these  three  bones  are  separated  by  the 
Y-shaped  cartilage.  At  puberty  the  cartilage 
begins  to  ossify,  and  by  the  eighteenth  year  the 
acetabulum  is  one  continuous  mass  of  bone.  The 
breaking-up  of  the  acetabulum  by  disease,  there- 
fore, is  only  possible  before  that  year. 

The  manner  in  which  the  various  movements 
at  the  hip  are  limited  may  be  briefly  expressed 
as  follows :  The  limit  of  every  natural  movement 
is  fixed  by  the  extensibility  of  the  muscles  which 
surround  a  joint.  That  is  readily  seen  at  the 
hip-joint,  for  when  the  knee  is  extended,  and 
the  hamstring  muscles  thus  tightened,  flexion  at 
the  hip  is  limited  long  before  the  ligaments  become 
tense.  Ligaments  only  come  into  play  when  the 
muscular  defence  of  the  joint  breaks  down.  Flexion, 
when  the  knee  is  bent,  is  limited  by  the  contact  of 
the  soft  parts  of  the  groin.  Extension,  by  the 
ilio-psoas,  rectus  femoris,  and  the  ilio-femoral  or 
Y -ligament.  Abduction,  by  the  adductor  mass  of 
muscles  and  the  pubo-capsular  ligament.  Adduction 
of  the  flexed  limb,  by  the  gluteal  musculature, 


xxn]  HIP-JOINT  DISEASE  543 

the  ligamentum  teres  and  ischio-capsular  liga- 
ment. Rotation  outwards  is  resisted  by  the  tensor 
fasciae  femoris,  the  anterior  parts  of  the  glutei 
medius  and  minimus,  and  the  ilio-femoral  liga- 
ment. The  ligamentum  teres,  which  is  not  a 
strong  ligament,  becomes  taut  when  the  thigh  is 
flexed  and  rotated  outwards.  It  is  ruptured  in 
all  cases  of  complete  dislocation.  The  structures 
which  take  the  chief  part  in  maintaining  the 
integrity  of  the  joint,  however,  are  not  the 
ligaments  but  the  strong  muscles  which  surround 
and  act  on  the  joint.  Atmospheric  pressure  bears 
no  part,  for  the  fat  at  the  transverse  notch  is 
readily  drawn  into  the  acetabulum  to  make  good 
any  space  vacated  by  the  femoral  head  in  all 
normal  movements  erf  the  hip-joint.  All  joints 
are  provided  with  yielding  pads  of  fat  to  obviate 
alterations  of  atmospheric  pressure  interfering 
with  movements  in  the  joint. 

Hip-joint  disease.— Owing  to  its  deep  position 
and  its  thick  covering  of  soft  parts  (Fig.  118), 
this  articulation  is  able  to  escape,  to  a  great 
extent,  those  severer  injuries  that  are  capable  of 
producing  acute  inflammation  in  other  joints. 
Acute  synovitis  is  indeed  quite  rare  in  the  hip, 
and  the  ordinary  disease  of  the  part  is  of  a  dis- 
tinctly chronic  character.  It  follows,  also,  from 
the  deep  position  of  the  articulation  that  pus, 
when  it  is  formed  in  connexion  with  disease,  re- 
mains pent  up.  and  is  long  bef credit  reaches  the 
surface.  Suppuration  in  this  region,  therefore, 
is  often  very  destructive.  When  effusion  takes 
place  into  the  joint,  the  swelling  incident  thereto 
will  first  show  itself  in  those  parts  where  the  hip 
capsule  is  the  most  thin.  The  thinnest  parts  of 
the  capsule  are  in  front  and  behind — in  front, 
in  the  triangular  interval  between  the  inner  edge 
of  the Y- ligament  and  the  pubo-capsular  ligament; 
behind,  at  the  posterior  and  lower  part  of  the 
capsule.  It  is  over  these  two  districts  that  the 
swelling  first  declares  itself  in  cases  of  effusion 
into  the  joint,  and,  as  these  parts  are  readily 


544 


THE    LOWER    EXTREMITY 


[CHAP. 


accessible  to  pressure,  it  follows  that  they  corre- 
spond also  to  the  regions  where  tenderness  is  most 
marked  and  is  earliest  detected.  Consequently  it 
is  over  these  two  weak  spaces  that  abscesses  form 
and  work  a  passage  to  the  surface  of  the  hip. 

In  chronic  hip-disease  certain  false  positions 
are  assumed  by  the  affected  limb,  the  meaning  of 
which  it  is  important  to  appreciate.  These  posi- 
tions may  be  arranged  as  follows,  according,  as 


C    A 


I  2 

Fig.  119.— Diagrams  of  positions  of  pelvis  and  limbs.  1, 
Parts  in  normal  position.  2,  Adduction  corrected 
by  tilting  up  the  pelvis.  3,  Femur  adducted. 

AC,  Line  of  pelvis:  AB,  limb  on  diseased  side;  CD,  limb  on  sound 
side ;  E,  the  spine.  It  will  be  found  that  in  diagrams  2  and  3  the 
angle  at  A  is  the  same  in  both. 

nearly  as  possible,  to  their  order  of  appearing : 
(1)  The  thigh  is  flexed,  abducted,  and  a  little 
everted ;  associated  with  this  there  is  (2)  apparent 
lengthening  of  the  limb  and  (3)  lordosis  of  the 
spine;  (4)  the  thigh  is  adducted  and  inverted, 
and  incident  to  this  there  is  (5)  apparent  shorten- 
ing of  the  limb.* 

(1)  The  first  position  is  simply  the  posture  of 


XXIl] 


HIP-JOINT   DISEASE 


545 


rest  for  the  surrounding  muscles — the  posture  in 
which  they  exert  the  least  pressure  on  the  joint- 
surfaces.  Flexion  is  the  most  marked  feature  in 
this  position.  Its  effect  is  pronounced.  It  re- 
laxes the  main  part  of  the  Y-  ligament,  which, 
when  the  limb  is  straight,  is  drawn  as  an  un- 
yielding band  across  the  front  of  the  joint.  The 
attachments  of  the 
psoas  muscle  are  ap- 
proximated and  its 
pressure  over  the 
joint  is  relaxed  in 
the  flexed  position. 

(2)  The   apparent 
lengthening    is    due 
to   the   tilting   down 
of  the  pelvis  on  the 
diseased     side    when 
the  patient  attempts 
to    bring    his    limbs 
and     trunk     into     a 
straight    line    as    he 
lies. on  his  back  (Fig. 
119).    Actually,  when 
measured    from    an- 
terior  superior   iliac 

spine    to    internal    „.       1    "     ~. 
malleolus,  the  limb  is    Fig.    120.-Diagram     to    show 
not  lengthened.     The  m.od?   of.Productlon  of 

pelvis  is  tilted  down-  A  pemtJJexed'at  hip  pelviT(repre- 
wards  on  the  dis-  '  sented  by  the  dotted  line)  straight 
eased  side,  to  accom-  and  spine  normal.  B,  The  flexion 
m/-»rlat«  fVi«  nKrln«fo/l  concealed  or  overcome  by  lordosis 
modate  the  abducted  of  the  spine.  the  peivis  rendered 

position    OI    the    dlS-         oblique. 

abled  limb. 

(3)  The  lordosis,  or  curving  forwards,   of  the 
spine  occurs  in  the  dorso-lumbar  region.     It  de- 
pends upon  the  flexion  of  the  limb,   and  is  the 
result  of  an  attempt  to  conceal  that  false  position, 
or  at  least  to  minimize  its  inconveniences  (Fig. 
120).     When   the   thigh   is   flexed    at  the   hip   by 
disease,   the  lower  limb  can  be  made  to  appear 

s 


B 


546  THE    LOWEK    EXTREMITY  [CHAP. 

straight  by  simply  increasing  the  forward  con- 
vexity of  the  lumbar  curvature  of  the  spine.  We 
have  to  keep  constantly  in  mind  that  the  spinal 
movements  of  the  loin  are  correlated  with  those 
at  the  hip-joints,  and  that  the  psoas  muscles  act 
on  both;  we  can  compensate  a  limitation  at  the 
hip-joint  by  overdoing  the  lumbar  movement,  thus 
producing  the,  lordosis  we  see  in  cases  of  hip- 
joint  disease.  A  patient  with  a  flexed  hip  as 
the  result  of  disease  can  lie  on  his  back  in  bed, 
with  both  limbs  apparently  perfectly  straight,  he 
having  concealed  the  flexion,  as  it  were,  by  pro- 
ducing a  lordosis  of  the  spine.  But,  as  Thomas 
was  the  first  to  show,  if  the  lordosis  be  undone 
by  flexing  the  sound  thigh  on  the  belly,  then  the 
flexed  position  of  the  thigh  on  the  diseased  side 
at  once  becomes  apparent.  This  lordosis  generally 
appears  a  little  late  in  the  disease,  and  after 
the  limb  has  become  more  or  less  fixed  in  the 
false  position  by  contraction  of  the  surrounding 
muscles. 

t  (4)  Sooner  or  later,  if  disease  progresses,  the 
thigh  becomes  adducted  and  inverted,  while  it 
still  remains  flexed.  Destruction  of  the  arti- 
cular surfaces  —  particularly  of  the  hinder 
part  of  the  acetabulum — disorganization  of  the 
capsule,  and  altered  action  of  the  surrounding 
musculature  produce  a  partial  or  complete  dis- 
location. 

(5)  The  apparent  shortening,  which  may  ap- 
pear at  a  late  stage,  is  produced  by  reversing 
the  tilting  which  appeared  in  the  earlier  stage 
when  the  diseased  limb  was  abducted.  The 
manner  in  which  the  pelvis  may  be  tilted  upwards 
to  produce  apparent  shortening  of  the  adducted 
limb  is  illustrated  in  Fig.  119,  2,  3.  In' some  cases 
of  simultaneous  disease  in  both  hip-joints  that 
has  been  indifferently  treated,  both  thighs  may 
remain  adducted.  The  limbs  are  unable,  of 
course,  to  remedy  their  position  by  the  usual 
means,  when  the  ^  disease  is  double,  and  conse- 
quently one  limb  is  crossed  in  front  of  the  other, 


xxn]  HIP-JOINT  DISEASE  547 

and  the  peculiar  mode  of  locomotion  known  as 
"cross-legged  progression"  is  produced. 

When  hip-disease  commences  in  the  bone  it 
usually  involves  the  epiphyseal  line  which  unites 
the  head  of  the  femur  to  the  neck.  This  line  is 
wholly  within  the  joint,  and  the  epiphysis  form- 
ing the  head  unites  with  the  rest  of  the  bone  about 
the  eighteenth  or  nineteenth  year.  (Fig.  118.) 

It  is  well  known  that  patients  with  hip-disease 
often  complain  of  pain  in  the  knee.  This  referred 
pain  may  be  so  marked  as  entirely  to  withdraw 
attention  from  the  true  seat  of  disease.  Thus, 
I  (F.  T.)  once  had  a  child  sent  to  me  with 
a  sound  knee  carefully  secured  in  splints,  but 
without  any  appliance  to  the  hip,  which  was  the 
seat  of  a  somewhat  active  inflammation.  This 
referred  pain  is  easy  to  understand,  since  the 
two  joints  are  supplied  from  the  same  segments 
of  the  spinal  cord.  In  the  hip,  branches  from  (1) 
the  anterior  crural  (femoral)  enter  at  the  front 
of  the  capsule;  (2)  branches  from  the  obturator, 
at  the  lower  and  inner  part  of  the  capsule;  and 
(3)  branches  from  the  sacral  plexus  and  sciatic 
nerve,  at  the  posterior  part  of  the  joint.  In  the 
knee,  branches  from  (1)  the  anterior  crural  (nerves 
to  vasti)  enter  at  the  front  of  the  capsule;  (2) 
branches  from  the  obturator,  at  the  posterior  part 
of  the  capsule ;  and  (3)  branches  from  the  internal 
and  external  popliteal  divisions  of  the  great 
sciatic  nerve,  at  the  lateral  and  hinder  aspects  of 
the  joint. 

Pain,  therefore,  in  the  front  of  the  knee,  on 
one  or  both  sides  of  the  patella,  has  probably  been 
referred  along  the  anterior  crural  curve;  and 
pain  at  the  back  of  the  joint,  along  the  obturator 
or  sciatic  nerves. 

In  hysterical  individuals  joint-disease  may  be 
imitated  by  certain  local  nervous  phenomena,  the 
articulation  itself  being  quite  free  from  struc- 
tural change.  This  affection  most  commonly 
shows  itself  in  the  hip  or  knee,  and  the  "  hys- 
terical hip,"  or  "hysterical  knee,**  takes  a  promi- 


548  THE    LOWER    EXTREMITY  [CHAP. 

nent  place  in  the  symptomatology  of  hysteria. 
It  is  not  quite  easy  to  understand  why  these  two 
large  joints  should  be  so  frequently  selected  for 
the  mimicry  of  disease.  Hilton  has  endeavoured 
to  explain  the  fact  upon  anatomical  grounds, 
having  reference  to  the  nerve  supply  of  these 
joints  in  relation  to  the  nerve  supply  of  the 
uterus.  The  uterus  is  mainly  supplied  by  an 
offshoot  from  the  hypogastric  plexus,  and  by  the 
third  and  fourth  sacral  nerves.  Now,  the  hypo- 
gastric  plexus  contains  filaments  derived  from  the 
lower  lumbar  nerves^  and  from  the  same  trunks 
two  nerves  to  the  hip  and  knee  (the  anterior 
crural  and  obturator)  are  in  great  part  derived. 
The  sciatic  also  contains  a  large  portion  "of 
the  third  sacral  nerve.  The  common  origin  of 
the  joint  and  uterine  nerves  forms  the  basis 
of  Hilton's  explanation  of  the  relative  frequency 
of  hysterical  disease  in  the  large  articulations  of 
the  lower  limb.  The  explanation,  however,  is  un- 
satisfactory, since  the  uterus  receives  many  of  its 
nerves  from  the  ovarian  plexus,  and  the  theory  is 
founded  upon  the  unwarranted  supposition  that 
all  hysterical  disorders  are  associated  with  some 
affection  of  the  uterus  or  its  appendages.  More 
recently  Head  has  revived  Hilton's  theory  in 
modified  form.  He  explains  the  connexion  not 
through  an  anatomical  association  of  nerves,  but 
through  an  association  of  the  centres  from  which 
nerves  arise  in  the  spinal  cord.  The  spinal  seg- 
ments from  which  the  obturator  nerve  arises,  the 
second,  third,  and  fourth,  contain  no  visceral 
nerves,  and,  therefore,  cannot  be  associated  with 
visceral  conditions.  On  the  other  hand,  the 
sacral  segments  from  which  the  great  sciatic 
nerve  arises  are  those  which  supply  the  pelvic- 
viscera. 

Fractures  of  the  upper  end  of  the  femur 
may  be  divided  into  (1)  fractures  of  the  neck 
wholly  within  the  capsule ;  (2)  fractures  of  the 
base  of  the  neck  not  wholly  within  the  capsule ; 
(3)  fractures  of  the  base  of  the  neck  involving  the 


xxn]     FRACTURES   OF  NECK   OF   FEMUR      549 

great  trochanter;  (4)  separations  of  epiphyses.  It 
can  be  scarcely  possible,  apart  from  gunshot  in- 
juries, to  fracture  the  neck  of  the  femur  by  direct 
violence,  owing  to  the  depth  at  which  the  bone 
is  placed,  and  the  manner  in  which  it  is  pro- 
tected by  the  surrounding  muscles.  The  violence, 
therefore,  that  causes  the  lesion  is  nearly  always 
indirect,  as  by  a  fall  upon  the  feet  or  great 
trochanter,  or  by  a  sudden  wrench  of  the  lower 
limb. 

(1)  The  true  intracapsular  fracture  may  involve 
any  part  of  the  cervix  within  the  joint,  but  is 
most  usually  found  near  the  line  of  junction  of 
the  head  with  the  neck  (Fig.  118,  p.  541).  This 
fracture  is  more  common  in  the  old,  in  whom 
it  may  be  produced  by  very  slight  degrees  of 
violence.  The  liability  of  the  aged  to  this  lesion 
is  explained  by  atrophy  of  the  supporting  and 
strengthening  trabeculse  and  by  a  lessened  pro- 
tective reflex  on  the  part  of  the  muscles.  The 
neck  of  the  femur  becomes  set  more  transversely 
as  old  age  comes  on.  In  youth  the  neck  forms 
an  angle  of  140°  with  the  shaft  of  the  femur; 
in  the  aged  the  angle  decreases  to  120°,  and  is 
thus  more  liable  to  fracture  when  a  false  step 
is  taken.  These  fractures  are  but  rarely  im- 
pacted; but  when  impacted,  the  lower  fragment, 
represented  by  the  relatively  small  and  compact 
neck,  is  driven  into  the  larger  and  more  cancel- 
lous  fragment  made  up  of  the  head  of  the  bone. 
The  fracture  may  be  subperiosteal,  or  the  frag- 
ments may  be  held  together  by  the  reflected  por- 
tion of  the  capsule.  These  reflected  fibres  pass 
along  the  neck  of  the  bone  from  the  attachment 
of  the  capsule  at  the  femur  to  a  point  on  the 
cervix  much  nearer  to  the  head.  Fractures  of 
this  part  very  often  fail  to  unite,  because  there 
is  no  part  of  the  body  which  is  so  difficult  to 
immobilize  as  the  top  of  the  femur.  The  pelvis 
as  well  as  the  femur  must  be  secured  in  a  fixed 
position  if  the  fragments  are  to  be  kept  at 
rest;  that  can  only  be  attained  by  immobilizing 


550  THE   LOWER   EXTREMITY 

the  lower  limbs  and  trunk.  Blood  is  brought  to 
the  head  of  the  femur  by  vessels  in  the  neck  of  the 
bone  and  in  the  reflected  parts  of  the  capsule, 
but  only  an  insignificant  supply  is  carried  by 
the  ligamentum  teres  (Walmsley).  A  deficiency 
in  the  blood  supply  to  the  fragments  has  been 
often  put  forward  to  explain  failures  of  union, 
but  there  is  no  real  evidence  to  support  this  con- 
tention. 

(2)  In  connexion  with  fractures  at  the  base 
of  the  neck,  it  must  be  remembered  that  a  wholly 
axtracapsular  fracture  of  the  neck  of  the  femur 
is  an  anatomical  impossibility.  If  the  fracture  is 
wholly  without  the  capsule,  then  it  must  involve  a 
part  of  the  femoral  shaft,  and  cannot  be  entirely 
through  the  cervix.  In  the  front  of  the  bone  the 
capsule  is  attached  to  the  femur  along  the  mter- 
trochanteric  line,  and  strictly  follows  the  line  of 
junction  between  the  cervix  and  the  shaft.  Be- 
hind, the  capsule  is  inserted  .into  the  neck  about 
^  an  inch  above  the  posterior  intertrochanteric 
line  or  crest.  When  fractures  at  the  junction  of 
the  neck  and  shaft  are  impacted,  the  upper  frag- 
ment, represented  by  the  compact  and  relatively 
small  cervix,  is  driven  into  the  cancellous  tissue 
about  the  great  trochanter  and  upper  end  of  the 
shaft  (Fig.  121).  As  a  result  of  this  impaction 
the  trochanter  may  be  split  up,  and  the  bones 
may  become  free  again  through  the  extent  of  this 
splintering.  The  impacted  end  of  the  cervical 
fragment  is  shaded  like  a  chisel ;  the  calcar 
femorale  forming  its  cutting  edge  (R.  Thompson). 

With  regard  to  the  symptoms  of  a  fracture 
of  the  neck  of  the  femur,  the  following  may  be 
noticed:  (a)  The  swelling  often  observed  in  the 
front  of  the  limb,  just  below  the  inguinal  liga- 
ment, is  due  either  to  effusion  of  blood  into  ^the 
joint  or  to  projection  of  the  fragments  against 
the  front  of  the  capsule ;  (6)  the  shortening  is 
brought  ab9ut  by  the  glutei,  the  hamstrings,  the 
tensor  fasciae  femoris,  the  rectus,  sartorius,  and 
ilio-psoas,  the  adductors,  gracilis,  and  pectineus; 


xxn]     FRACTURES   OF  NECK  OF  FEMUR       551 

(c)  the  eversion,  or  rotation  outwards  of  the  limb, 
is  mainly  due  to  two  causes  :  (i)  the  weight  of 
the  limb,  which  causes  it  to  roll  outwards,  as  is 
seen  in  persons  insensible  or  asleep,  the  line  of 
gravity  passing  through  the  outer  part  of  the 
thigh ;  (ii)  the  fact  that  the  compact  tissue  on  the 
posterior  aspect  of  the  neck  is  much  more  fragile 
than  that  on  the  anterior  aspect.  Thus  the  cervix 
is  often  more  extensively  fractured  behind  than  in 
front,  or  the  fracture  may  be  impacted  behind 


ANT.  DENSE  LAYER 


CALCAR    FEMORALE 


ANT.  FRAGMENT  OF 
GREAT   TROCHANTER 


Fig,  121. — The  calcar  femorale  and  its  relationship  to 
impacted  fractures  of  the  neck  of  the  femur.  (Ralph 
Thompson. ) 

but  not  in  front,  and  in  either  case  the  limb  will 
tend  to  become  everted.  As  a  third  cause  may 
be  mentioned  the  action  of  the  ilio-psoas,  of  the 
adductor  and  pectineus  muscles,  and  of  the  small 
rotator  muscles,  all  of  which  will  tend  to  roll  the 
femur  outwards. 

(3)  Fracture  of  the  base  of  the  neck  involving 
the  great  trochanter. — In  this  lesion  the  head, 
the  cervix,  and  a  part  of  the  great  trochanter 
are  separated  from  the  shaft  and  the  rest  of  the 
trochanter. 


552  THE    LOWER    EXTREMITY          [CHAP. 

(4)  Separation  of  epiphyses. — There  are  three 
epiphyses  in  the  upper  end  of  the  femur — one  for 
the  head,  which  unites  between  18  and  19  years 
of  age;  one  for  the  lesser  trochanter,  which  unites 
about  17;  and  one  for  the  greater  trochanter, 
which  unites  about  18.  The  neck  is  formed  by 
an  extension  of  ossification  from  the  shaft  (Fig. 
122).  The  epiphysis  for  the  head  is  secured 
against  separation  by  being  shaped  like  a  cap, 
by  its  epiphyseal  line  being  arranged  trans- 
versely to  the  axis  of  the  femur,  and  also  by  its 
intracapsular  position  (Fig.  118).  The  epiphysis, 
however,  is  subject  to  a  peculiar  form  of  disloca- 


Fig.  122. — Illustrating    the     ossification     of   the     upper 
end   of  the  femur  and  the  condition  of  coxa  vara. 

(After  ElmsUe.) 

A,  The  upper  end  at  birth. 

B,  „          „          at  second  year. 
c,       „          „          at  fourth  year. 

D,       „          „          of  a  femur  from  a  subject  of  coxa  vara. 

tion  which  gives  rise  to  the  condition  of  coxa  vara. 
The  epiphysis  gradually  tilts  downwards  so  that 
the  neck  of  the  femur  appears  to  sink  under  the 
weight  of  the  body,  coming  to  form  an  angle  of 
90°  or  less  with  the  shaft  of  the  femur.  It  occurs 
in  adolescents.  Owing  to  the  prominence  of  the 
trochanter  and  shortening  of  the  limb  which 
necessarily  result,  the  condition  may  be  mistaken 
for  a  fracture  of  the  neck  of  the  femur  or  a 
congenital  dislocation  of  the  hip-joint.  In  para- 
lytic limbs  the  opposite  condition,  coxa  valga,  is 
found.  The  angle  may  measure  145°  or  more.  The 


XXIl] 


DISLOCATIONS   OF  THE   HIP 


553 


great  trochanter  may  be  separated.  The  epi- 
physeal  lines  of  the  head  and  great  trochanter 
are  continuous  until  the  neck  is  ossified  (see 
Fig.  122). 

Dislocations  of  the  hip. —  These  injuries 
are  comparatively  rare,  on  account  of  the  great 
strength  of  the  articulation,  and  when  they  occur 
in  a  healthy  joint  are  always  the  result  of  a  con- 
siderable degree  of  violence.  A  dislocation  of  the 
hip  may  be  congenital,  or  may  be  spontaneously 


SACRUM 


SyiAjeEa  CARTIUACB 

ACETABULUM 

P0BES 


QRT.TROCMAflTER 


PECTI/IEUS 
ADDUCTOR  Lortcus 
CAPSULE 
PSOAS 


Fig.  123. — Congenital  dislocation  of  the  hip. 

From  a  specimen  presented  to  the  London  Hospital  Medical  College 
Museum  by  Mr.  Openshaw.  It  was  obtained  from  a  child  aged 
4  years. 

produced  by  muscular  efforts,  as  shown  in  a  few 
rare  cases,  or  may  be  the  result  of  disease  of  the 
articulation.  Congenital  dislocation  of  the  hip- 
joint  is  due  in  most  instances  to  a  failure  in  the 
development  of  the  acetabulum.  In  such  cases 
the  acetabulum  retains  the  shallow  character  seen 
during  the  second  month  of  foetal  life.  The  out- 
growth of  the  acetabular  rim  fails,  especially  in 
the  iliac  part.  The  acetabular  cavity  becomes 
filled  up  by  the  duplication  of  the  capsule,  which 
is  unduly  lax  (Fig.  123).  The  round  ligament 
s* 


554  THE    LOWER    EXTREMITY          [CHAP. 

may  be  intact  or  deficient.  The  head  of  the  femur 
becomes  flat  and  the  neck  short,  and  the  bone 
slips  backwards  on  the  dorsum  ilii  when  the  child 
learns  to  walk.  The  weight  of  the  body  is  sup- 
ported by  the  muscles  and  ligaments  round  the 
hip-joint,  and  the  gait  of  the  patient  resembles  the 
waddle  of  a  duck.  If  replaced  the  head  again  slips 
from  the  shallow  cavity.  In  time  osteophytic  out- 
growths from  the  ilium  lead  to  the  ^  formation  of 
a  new  cavity.  The  deformity  is  evidently  corre- 
lated with  the  development  of  the  female  sexual 
organs,  for  it  occurs  nearly  nine  times  more 
frequently  in  female  than  in  male  children 
(Fairbanks). 

In  dislocations  due  to  violence  the  head  of  the 
bone  may  be  found  displaced   in  either   of   four 
directions,    producing   the    four    regular    disloca- 
tions of  the  hip.     In  two  the  head  of  the  femur 
is  posterior   to   a  line  drawn  vertically   through 
the  acetabulum,  and  in  the  other  two  it  is  found 
anterior  to  that  line  (see  Figs.  124,  125,  and  126). 
(1)  Backwards  and  upwards.     Head  rests  upon 
ilium,    just  above   and  behind   acetabulum.     The 
"dislocation  upon   the  dorsum  ilii."     (2)    Back- 
wards.   Head  rests  upon  ischium,  and,  as  a  rule, 
about  on  a  level  with  the  ischial  spine.     The  "  dis- 
location into   the  sciatic  notch."      (3)    Forwards 
and  downwards.     Head  rests  on  thyroid  foramen. 
The  "  obturator  or  thyroid  dislocation."     (4)  For- 
wards and  upwards.     Head  rests  upon  the  body 
of  the  pubes,  close  to  its  junction  with  the  ilium. 
The  "dislocation  upon  the  pubes." 

The  above  arrangement  represents  also  the 
order  of  frequency  of  these  luxations.  No.  1  being 
the  most  common  dislocation  of  this  part,  and 
No.  4  the  most  rare. 

General  facts.— In  all  these  dislocations  of  the 
hip,  (a)  the  luxation  occurs  when  the  limb  is 
in  the  position  of  abduction;  (b)  the  rent  in  the 
capsule  is  always  at  its  posterior  and  lower 
part;  (c)  the  head  of  the  bone  always  passes 
at  first  more  or  less  directly  downwards;  (d)  the 


xxn]  DISLOCATIONS   OF  THE  HIP  555 

Y-ligament  is  untorn,  while  the  ligamentum  teres 
is  ruptured. 

(a)  It  is  maintained  that,  in  all  luxations  at 
the  hip,  the  pelvis  and  femur  are  in  the  mutual 
position  of  abduction  of  the  latter  at  the  time 
of  the  accident.  The  lower  and  inner  part  of 
the  acetabulum  is  very  shallow,  and  the  lower  and 
posterior  part  of  the  capsule  is  very  thin.  In 
abduction  the  head  of  the  bone  is  brought  to  the 
shallow  part  of  the  acetabulum;  it  moves  more 
than  half  out  of  that  cavity;  it  is  supported 
only  by  the  thin  weak  part  of  the  capsule,  and  its 
further  movement  in  the  direction  of  abduction 
is  limited  only  by  the  pubo-capsular  ligament,  a 
somewhat  feeble  band.  In  abduction  the  round 
ligament  is  slack,  and  in  abduction  with  flexion 
both  the  Y-ligament  and  the  ischio-capsular  liga- 
ments are  also  relaxed.  In  the  position  of  abduc- 
tion, therefore,  no  great  degree  of  force  may  be 
required  to  thrust  the  head  of  the  bone  through 
the  lower  and  posterior  part  of  the  capsule  and 
displace  it  downwards. 

(6)  The  above  being  allowed,  it  will  be  under- 
stood that  the  rent  in  the  capsule  is  always  at  its 
posterior  and  lower  parts.  "  Generally  the  rup- 
ture is  jagged  and  irregular,  but  will  be  found 
to  extend  more  or  less  directly  from  near  the 
shallow  rim  of  the  acetabulum,  across  the  thin 
portion  of  the  capsule  to  the  femur  near  the  small 
trochanter,  and  then  to  run  along  the  back  of  the 
ligament  close  to  its  attachment  to  the  neck  of 
the  bone"  (Sir  Henry  Morris). 

(c)  If  the  position  of  the  limb  at  the  time  of 
the  accident  be  considered,  it  ;will  be  seen  that  the 
femur  will  in  every  case  be  displaced  downwards. 
There  is,  indeed,  but  one  primary  dislocation  of 
the  hip— a  luxation  downwards.     The  four  forms 
given  above  are  all  secondary,  the  bone  having  in 
each   instance   first   passed   downwards   before    it 
moved  to  any  of  the  positions  indicated. 

(d)  The    ilio-femoral   ligament   is    never   torn 
in   any   regular  dislocation.     It  is  saved  by   its 


556 


THE    LOWER    EXTREMITY 


[CHAP. 


great  density  and  the  circumstance  that  it  is 
probably  more  or  less  relaxed  at  the  time  of 
the  luxation.  The  method  of  reducing  these 
dislocations  by  manipulation  depends  for  its 
success  mainly  upon  the  integrity  of  the  ilio- 
femoral  or  Y -ligament,  which  acts  as  the  ful- 
crum to  a  lever  of  which  the  shaft  of  the  femur 
is  the  long  arm  and  the  neck  the  short.  In 
the  backward  luxations  the  head  is  behind  the 

Y-ligament,  and 
in  the  forward 
displacements  in 
front  of  it. 

The  anatomy 
of  each  form  of 
hip  dislocation. 
Nos.  1  and  2  : 
The  dislo  ca- 
tions backwards 
(Fig.  124).— The 
femoral  head, 
having  been  dis- 
placed in  the 
way  indicated,  is 
carried  towards 
the  dorsum  or 
sciatic  notch  by 
the  glutei,  ham- 
string, and  ad- 
ductor muscles. 
The  bone  having 
taken  a  general 
direction  backwards,  the  height  to  which  it  ascends 
depends  mainly  upon  the  nature  of  the  dislo- 
cating force,  and  also  upon  the  extent  of  the 
rupture  in  the  capsule  and  the  laceration  of 
the  obturator  internus  tendon  and  other  small 
external  rotators.  The  dorsal  dislocation  is, 
therefore,  a  more  advanced  grade  of  the  sciatic. 
The  more  extreme  the  flexion  and  inward  rota- 
tion at  the  time  of  the  accident,  the  more  likely 
is  the  dislocation  to  be  sciatic.  More  moderate 


Fig.  124.—  Dislocation    upon    the 
dorsum  ilii.     (Bigelow.) 


xxn]    BACKWARD  DISLOCATION   OF  HIP       557 

flexion  and  inward  rotation  will  produce  a 
luxation  upon  the  dorsum.  In  the  dorsal  luxa- 
tion the  head  is  above  the  obturator  internus 
tendon,  while  in  the  sciatic  form  it  is  below  it 
(Bigelow).  In  these  backward  dislocations  the 
ilio-psoas  muscle  is  greatly  stretched.  The  quad- 
ratus  femoris,  the  obturators,  the  gemelli,  and 
the  pyriformis  are  more  or  less  lacerated.  The 
pectineus  is  often  torn,  and  the  glutei  muscles  even 
may  be  ruptured  in 
part.  The  sciatic 
nerve  may  be  com- 
pressed between  the 
femoral  neck  and 
the  rotator  muscles, 
or  between  the  head 
of  the  bone  and 
the  tuber  ischii.  In 
both  of  the  back- 
w  a  r  d  luxations 
there  is  shortening 
due  to  the  circum- 
stance that  the  line 
between  the  ante- 
rior superior  spine 
and  the  femoral 
condyles  is  lessened 
by  the  displace- 
ment upwards  and 


Tfc         M          Fig'   ^.-Obturator  or    thyroid 
The    adduc-  dislocation.     (Sigeloiv.} 

tion    and    inversion 

in  the  main  depend  upon  the  position  of  the 
head  and  cervix,  which  must  follow  the  plane 
of  the  bone  upon  which  they  lie.  This  position  is 
maintained  by  the  tense  Y  -ligament.  The  damage 
done  to  the  chief  external  rotators  places  them  also 
hors  de  combat.  The  flexion  is  due  to  the  tension 
of  the  Y-ligament  and  of  the  ilio-psoas  muscle. 

Nos.    3   and  4  :   The  dislocation  forwards. If 

the  head  after  leaving  the  acetabulum  simply 
moves  a  little  forwards  along  the  inner  edge 


558 


THE    LOWER    EXTREMITY 


[CHAP. 


of  the  socket,  the  thyroid  luxation  is  produced 
(Fig.  125).  If  it  goes  farther  and  moves  upwards, 
the  pubic  displacement  will  result  (Fig.  126). 
The  latter  dislocation  is  therefore  but  an  ad- 
vanced form  of  the  former.  Whether  the  head 
will  remain  in  the  thyroid  foramen  or  ascend  on 
to  the  pubes  depends  on  whether  extension  and 

rotation  outwa  rds 
accompany  the  dis- 
placement. If  these 
occur  the  pubic  form 
is  produced.  In 
these  injuries  the  pec- 
tineus,  gracilis,  and 
adductors  will  be  more 
or  less  torn,  while  the 
ilio-psoas,  glutei,  and 
pyriform  muscles  are 
much  stretched.  The 
obturator  nerve  may 
be  stretched  or  torn, 
and  in  the  pubic 
luxation  the  anterior 
crural  nerve  may  be 
involved.  The  abduc- 
tion and  eversion  of 
the  limb  noticed  in 
these  luxations  depend 
partly  upon  the  posi- 
tion of  the  head  of 

Fig.    126.-Dislocation   upon      the    J30116'  ,  fixef,    m°J? 
the  pubes.     (Bigeloiv.}  or      ^ss      by    .,tne       *' 

ligament,    and    partly 

upon  the  action  of  the  gluteal  muscles  and 
some  of  the  small  external  rotators,  which  are 
tightly  stretched.  The  flexion  of  the  limb  is 
mainly  due  to  the  stretching  of  the  ilio-psoas 
muscle. 

In  the  thyroid  luxation  the  extremity  is  said 
to  be  lengthened.  This  lengthening  is,  however, 
only  apparent,  and  is  due  to  the  tilting  down  of 
the  pelvis  on  the  injured  side.  In  the  pubic 


xxn]  AMPUTATION   AT   HIP-JOINT  559 

dislocation   there    is   shortening,    the  head   being 
carried  above  the  acetabular  level. 

Of  the  modes  of  reducing  these  dislocations 
by  manipulation  little  can  be  said  here.  The 
more  usual  proceedings  may  be  briefly  summarized 
as  follows  : 

First. — Flex  the  thigh  in  the 
adducted     position 

in    luxations    Nos.    m 

T   OT,J  o  To  relax  the  ilio- 

L     clilLl     &•  ,»  i  ^f 

femoral     or     Y- 
shaped  ligament. 


Flex  the  thigh  in  the 
abducted  position 
in  luxations  Nos. 
3  and  4.  ) 


o  ^«  L    •     /To  brine  back  the 

A6C07k%.-Circumduct  out,  in     head   £  the   rent 

Nos    1  and  2.        _     I  in  th    capsule  by 
Circumduct      m,       in  ]  th    routo  £   which 
Nos.  3  and  4.  (  it  hag 


Thirdly.  —  Extend    in    all    cases.     To    induce    the 
head  to  enter  the  acetabulum  again. 

In  reducing  dislocations  of  the  hip  it  may  be 
noted  that  the  internal  condyle  of  the  femur  faces 
in  nearly  the  same  direction  as  the  head  of  the 
bone. 

In  amputation  of  the  thigh  at  the  hip- 
joint  many  methods  may  be  employed,  but  there 
is  a  consensus  of  opinion  that  it  is  wise  to  design 
the  operation  so  that^  the  femoral  vessels  may  be 
secured  in  the  preliminary  incision.  In  dis- 
articulation  by  a  racquet-shaped  incision,  the 
part  representing  the  handle  is  placed  over 
the  upper  3  inches  of  the  femoral  artery,  com- 
mencing above  at  the  inguinal  ligament,  and  the 
elliptical  part  is  carried  round  the  inner  side  of 
the  limb,  4  inches  below  the  pubic  spine,  and 
brought  up  on  the  outer  side,  below  the  great 
trochanter.  The  surface  markings  for  the  femoral 
artery  are  given  at  p.  512;  the  origin  of  the  deep 
femoral  artery  and  its  circumflex  branches  lie 


560  THE    LOWER    EXTREMITY 

about  1|  inches  below  the  inguinal  ligament,  but 
it  is  frequently  ^  an  inch  higher  or  lower.  The 
common  femoral  is  separated  from  the  capsule  of 
the  hip-joint  by  the  psoas  muscle;  the  femoral 
vein  lies  close  to  its  inner  side,  and  the  anterior 
crural  nerve  ^  an  inch  to  its  outer  side,  on  the 
psoas  muscle  (see  Fig.  118,  p.  541).  Branches  of  the 
sciatic  and  obturator  arteries  also  enter  the  thigh 
and  require  to  be  secured.  The  nerves  divided  are  : 
the  external,  middle,  and  internal  cutaneous,  the 
internal  saphenous,  the  deep  muscular  branches 
of  the  anterior  crural,  the  obturator,  the  great 
and  small  sciatic.  The  muscles  divided  are:  the 
sartorius,  quadriceps  extensor  cruris,  adductors 
magnus  and  longus,  gracilis,  and  hamstrings. 
The  capsule  of  the  joint  is  divided,  the  head  of 
the  femur  thrust  from  its  socket,  and  the  liga- 
mentum  teres  cut.  The  attachments  of  the  follow- 
ing structures  to  the  upper  third  of  the  femur 
have  to  be  separated :  the  glutens  maximus, 
medius,  minimus,  pyriformis,  gemelli,  obturator 
internus  and  externus,  quadratus  femoris,  ad- 
ductor magnus,  brevis,  pectineus,  psoas,  and  ilia- 
cus,  with  the  capsular  ligament. 


CHAPTER   XXIII 
THE   THIGH 

UNDER  the  term  "  the  thigh  "  it  will  be  convenient 
to  describe  that  part  of  the  lower  limb  that  ex- 
tends between  the  regions  just  described  and  the 
districts  of  the  knee  and  popliteal  space. 

Surface  anatomy.— In  muscular  subjects  the 
outline  of  the  thigh  is  irregular,  but  in  the  less 
muscularly  developed,  who  are  provided  with  a 
good  share  of  subcutaneous  fat,  the  limb,  in  this 
section  of  it,  is  more  or  less  evenly  rounded.  The 
prominence  of  the  rectus  muscle  is  noticeable  on 
the  front  of  the  thigh,  especially  when  the  muscle 
is  in  action.  To  the  inner  side  of  this  structure, 
and  conspicuous  along  the  lower  half  of  the  thigh, 
is  the  eminence  formed  by  the  vastus  interims 
(medialis).  The  mass  to  the  outer  side  of  the 
rectus  is  composed  of  the  vastus  externus  (later- 
alis)  muscle,  and  occupies  the  greater  part  of 
the  limb  in  this  region,  being,  however,  more 
conspicuous  below. 

Running  down  the  anterior  and  inner  aspect  of 
the  thigh,  from  the  apex  of  the  femoral  (Scarpa's) 
triangle,  is  a  depression  which  indicates  the  interval 
between  the  quadriceps  muscle  and  the  adductors. 
Along  this  groove  the  sartorius  lies.  Over  the 
surface  of  the  vastus  externus  a  longitudinal 
depression  is  often  to  be  observed,  formed  by  the 
pressure  exercised  by  the  superimposed  ilio-tibial 
band  of  the  fascia  lata.  The  hamstring  muscles 
cannot  generally  be  distinguished  the  one  from 
the  other  above  the  popliteal  space,  nor  is  their 
separation  from  the  adductors  indicated.  The 
separation,  however,  between  them  and  the  vastus 
561 


562  THE    LOWER    EXTREMITY          [CHAP. 

externus  is  distinct,  and  corresponds  to  the  posi- 
tion of  the  external  intermuscular  septum.  The 
line  of  the  femoral  vessels  has  already  been  given 
(p.  534).  The  long  saphenous  vein  follows  in 
the  thigh  the  course  of  the  sartorius  muscle,  and 
may  be  represented  on  the  surface  by  a  line  drawn 
from  the  region  of  the  saphenous  opening  (p.  534) 
to  the  posterior  border  of  the  sartorius  muscle 
at  the  level  of  the  inner  (medial)  condyle  of 
the  femur.  The  long  saphenous  nerve  follows 
the  course  of  the  femoral  artery,  lying  first  to 
the  outer  side  of  that  vessel  and  then  gradually 
crossing  it.  In  the  lower  fourth  of  the  thigh 
the  nerve  passes  under  cover  of  the  sartorius 
muscle  to  the  inner  side  of  the  knee,  and  is 
accompanied  by  the  superficial  (saphenous)  branch 
of  the  anastomotic  artery.  A  line  drawn  down 
the  back  of  the  limb  from  a  point  midway  be- 
tween the  great  trochanter  and  tuber  ischii  to 
the  middle  of  the  ham  will  correspond  to  the 
great  sciatic  nerve  and  one  of  its  continuations, 
the  internal  popliteal  or  tibial.  The  great  trunk 
usually  bifurcates  a  little  below  the  middle  of 
the  thigh. 

The  skin  of  the  thigh  is  coarse  on  the  outer 
side  of  the  limb,  but  internally  it  is  thin  and  fine, 
and  is  apt  to  be  readily  excoriated  by  ill-applied 
bandages  or  splints.  It  is  but  loosely  attached  to 
the  subjacent  parts,  a  circumstance  that  greatly 
favours  the  performance  of  circular  amputations 
in  this  region.  At  one  place,  however,  it  is  a 
little  more  adherent,  viz.  along  the  groove  that 
separates  the  vastus  externus  from  the  hamstring 
muscles,  and  that  corresponds  to  the  outer  inter- 
muscular  septum.  The  laxity  of  the  subcutaneous 
tissue  favours  extensive  extravasations  beneath 
the  skin,  and  permits  of  large  flaps  of  integu- 
ment being  torn  up  in  cases  of  injury  to  this  part 
of  the  extremity. 

The  fascia  lata  invests  the  limb  at  all  parts 
like  a  tightly  fitting  sleeve.  It  is  thickest  at  its 
outer  side,  where  it  forms  the  dense  ilio-tibial 


xxm]  FASCIA  LATA  563 

band.  It  is  thinnest  at  the  upper  and  inner 
aspect  of  the  thigh,  where  it  covers  the  adductor 
muscles.  It  increases  considerably  in  strength  as 
it  approaches  the  front  of  the  knee,  and  attaches 
itself  to  the  tibia  and  lateral  margins  of  the 
patella.  This  fascia  resists,  especially  at  its  outer 
part,  the  growth  of  tumours  and  abscesses,  and 
limits  deep  extravasations  of  blood.  It  has  occa- 
sionally been  ruptured  in  part  by  violence,  and 
through  the  rent  so  formed  the  subjacent  muscle 
has  bulged,  forming  what  is  known  as  a  hernia 
of  the  muscle.  This  condition  has  been  met  with 
in  the  case  of  the  quadriceps  muscle,  and  also 
of  the  adductor  longus.  Such  "  hernise  "  are 
probably  associated  with  some  rupture  of  the  fibres 
of  the  muscles  implicated.  Two  deep  processes 
of  the  fascia  are  attached  to  the  femur,  and 
form  the  outer  and  inner  intermuscular  septa. 
The  outer  septum  separates  the  vastus  externus 
from  the  biceps,  and  the  inner  the  vastus  internus 
from  the  adductors.  Together  with  the  fascia 
lata,  these  septa  divide  the  thigh  into  two  apo- 
neurotic  spaces,  which  can  be  displayed  in  a 
transverse  section  of  the  limb  (Fig.  127).  These 
divisions,  however,  are  of  little  surgical  moment, 
and  the  inner  septum  is  often  so  thin  and  feeble 
that  it  could  have  but  little  effect  in  directing 
the  course  of  an  abscess. 

In  circular  amputations  of  the  thigh  the 
muscles  are  apt  to  retract  unevenly,  since  some 
are  attached  to  the  femoral  shaft  while  others 
are  free.  The  muscles  so  attached  are  the  ad- 
ductors, vasti,  and  crureus  (vastus  intermedius), 
while  the  free  muscles  are  the  sartorius,  rectus, 
hamstrings,  and  gracilis.  Indeed,  the  retrac- 
tility of  tissues  must  be  kept  in  mind  in  all 
amputations.  The  bone,  which  has  to  be  covered, 
is  non-retractile.  Nerves  retract  very  little,  and 
are  apt  to  swell  into  bulbous  and  sensitive  ends 
unless  cut  very  short.  Arteries,  on  the  other 
hand,  are  highly  retractile;  veins  are  less  elastic 
and  tend  to  retract  less. 


564  THE    LOWER    EXTREMITY          [CHAP. 

In  spite  of  its  great  strength  the  tendon 
of  the  quadriceps  may  be  ruptured  by  muscular 
violence.  A  good  example  of  such  an  accident 
is  recorded  by  Mr.  Bryant  (Med.  Times  and  Gaz., 
1878).  A  man  aged  42  stumbled  and  fell  down  a 
pit  10  feet  deep.  On  examination  the  tendon  was 
found  to  be  torn  across,  and  the  gap  above  the 
patella  produced  by  the  rupture  occupied  no  less 
extent  than  the  lower  third  of  the  thigh.  A  some- 
what more  remarkable  accident  is  reported  to  have 
happened  to  the  sartorius  muscle.  This  muscle, 
just  before  its  insertion  into  the  tibia,  gives  off 
an  aponeurotic  expansion  from  its  anterior  bor- 
der to  the  capsule  of  the  knee-joint.  In  the  case 
alluded  to  (Lancet,  1873),  this  expansion  is  said 
to  have  been  ruptured,  and  the  muscle  itself  to 
have  been  found  dislocated  backwards  in  con- 
sequence. The  accident  befell  a  man  aged  40, 
who  was  squatting,  in  the  position  assumed  by 
tailors,  upon  the  floor  of  a  wagon,  when  his  com- 
panion tripped  over  him  and  fell  across  his  bent 
knees.  Something  was  felt  to  have  given  way 
near  the  ham,  and  on  examination  the  above  lesion 
was  diagnosed. 

The  femoral  artery  may  be  ligatured  at  any 
part  of  its  course  in  the  thigh,  and  the  com- 
paratively superficial  position  of  the  vessel  ren- 
ders it  very  liable  to  be  injured.  In  the  middle 
third  of  the  thigh  it  lies  beneath  the  sartorius  in 
the  adductor  (Hunter's)  canal.  The  thigh  affords 
many  instances  of  the  remarkable  way  in  which 
isolated  branches  of  a  main  artery  are  often 
alone  damaged.  Thus,  Langier  relates  the  case 
of  a  man-cook  who,  in  running  round  a  table, 
struck  the  upper  and  outer  side  of  his  thigh 
against  the  corner  of  it.  This  led  to  a  sub- 
cutaneous rupture  of  the  external  circumflex 
artery.  Unfortunately  the  extravasation  was  cut 
into,  and  the  patient,  after  being  subjected  to 
many  modes  of  treatment,  died  from  the  effects 
of  repeated  haemorrhage.  Dr.  Butcher  (Dublin 
Journ.  Med.  Sci.,  1874)  gives  the  case  of  a  man 


xxm]    FRACTURES  OF  SHAFT  OF  FEMUR       565 

who  was  stabbed  in  the  thigh  over  the  femoral 
vessels  during  a  scuffle.  Profuse  bleeding  fol- 
lowed, and  it  was  found  that  the  only  vessel 
wounded  was  the  internal  circumflex  artery,  just 
at  its  point  of  origin  from  the  profunda.  The 
case  was  treated  promptly,  and  the  man  did 
well.  On  the  other  hand,  cases  have  been  recorded 
during  the  Great  War  in  which  the  femoral 
artery  and  vein  were  completely  severed  by  a 
bullet  wound,  and  yet  only  slight  haemorrhage 
resulted.  In  these  cases  it  was  found  that  the 
ruptured  ends  had  become  widely  separated,  and 
that  the  edges  had  become  in-turned  within  the 
lumina  of  the  vessels. 

Fractures  of  the  shaft  of  the  femur. — The 
shaft  may  be  broken  at  any  part,  but  the  lesion 
is  most  common  at  the  middle  third  of  the  bone, 
and  least  frequent  at  its  upper  third.  If  it  is 
broken  by  direct  violence  the  fracture  is  usually 
transverse,  and  if  by  indirect  violence  it  is  usually 
oblique.  The  probability  of  a  fracture  being  due 
to  direct  violence  diminishes  in  the  bone  from 
below  upwards,  while  the  probability  of  a  lesion 
from  indirect  violence  increases  in  the  same  direc- 
tion. Thus  it  happens  that  the  fractures  of  the 
tipper  third  of  the  bone  are  usually  oblique,  while 
those  of  the  lower  third  are  more  commonly 
transverse.  The  femur  has  often  been  broken  by 
muscular  violence,  but  it  is  doubtful  if  this 
has  ever  occurred  in  other  than  a  diseased  bone. 
In  many  of  these  cases  the  amount  of  force 
that  breaks  the  bone  is  most  insignificant.  Thus, 
Vail  in  reports  the  case  of  a  girl  aged  18,  de- 
scribed as  robust,  who  broke  the  femur  about  its 
middle  while  in  the  act  of  mounting  a  table  for 
the  purpose  of  undergoing  a  vaginal  examination. 
In  oblique  fractures  in  the  upper  third  of  the  bone 
the  line  of  fracture  usually  runs  downwards  and 
inwards ;  while  in  oblique  fractures  of  the  middle 
third  the  direction  is  more  commonly  downwards 
and  forwards^  with^  a  slight  lateral  inclination 
that  is  sometimes  inwards  and  sometimes  out- 


566  THE    LOWER    EXTREMITY          [CHAP. 

wards.  Fractures  of  the  lower  third  of  the  bone 
are  discussed  in  connexion  with  the  region  of  the 
knee  (Chap.  xxiv.). 

With  regard  to  fractures  of  the  upper  and 
middle  thirds,  the  displacements  of  the  fragments 
depend  greatly  upon  the  obliquity  of  the  fracture. 
As  a  rule  the  lower  fragment  is  drawn  up  behind 
the  upper  one  by  the  hamstrings,  aided  by  the 
rectus,  gracilis,  sartorius,  tensor  fasciae,  and 
adductors,  and  is  carried  a  little  to  its  inner  side 
under  the  influence  of>  the  last-named  muscles. 
The  lower  end  of  the  upper  fragment  usually 
projects  forwards  and  a  little  outwards.  This 
is  due  to  the  agency  of  the  lower  fragment, 
which  tilts  the  upper  piece  of  bone  in  the  direction 
named.  In  the  fracture  of  the  upper  third  of  the 
shaft  the  projection  forwards  of  the  upper  frag- 
ment is  aided  by  the  ilio-psoas  muscle.  Thus  the 
deformity  produced  in  fractures  of  the  femoral 
shaft  is  usually  angular  in  character.  The  ever- 
sion  of  the  foot  noted  in  fractures  of  the  femur  is 
due  to  the  weight  of  the  limb,  which  causes  the 
helpless  member  to  roll  outwards. 

Certain  spiral  or  helicoidal  fractures  may  be 
produced  in  the  lower  part  of  the  shaft  as  the 
result  of  torsion.  M.  Fere  found  'by  experiment 
that  if  the  limb  be  carried  forwards  in  front 
of  the  opposite  knee,  and  the  foot  rotated  out- 
wards, a  spiral  fracture  can  be  produced  at  the 
junction  of  the  lower  and  middle  thirds  of  the 
femur.  A  like  fracture  at  ^the  same  level,  but 
with  the  direction  of  the  spiral  reversed,  can  be 
caused  by  carrying  the-  limb  outwards  and  then 
rotating  it  inwards. 

Shortening:  of  the  limb  after  fracture.— 
The  chief  difficulty  in  setting  the  broken  ends 
and  maintaining  them  in  position  lies  in  the 
action  of  the  surrounding  muscles.  From  the 
moment  of  fracture  onwards  all  the  muscles  of 
the  neighbourhood  pass  into  a  state  of  reflex 
contraction.  That  contraction  can  be  overcome 
by  a  general  or  local  anaesthesia,  and  the  parts 


xxin]       SHORTENING   OF  THE  FEMUR  567 

can  then  be  set  in  their  proper  position.  To 
maintain  the  parts  in  position  two  principles 
must  be  kept  in  mind:  (1)  impulses  which 
produce  reflex  contraction  must  be  prevented  by 
complete  immobilization  of  the  joints,  and  there- 
fore of  the  muscles,  of  the  limb;  (2)  the  retrac- 
tility of  the  muscles  must  be  gradually  overcome 
by  applying  a  continuously-acting  extending 


Fig.  127. — Transverse  section  through  the  middle  of  the 
thigh.     (Braune. ) 

a,  Rectus  femoris  ;  b.  vastus  externus  ;  c,  crureus  ;  d,  vastus  interims  ; 
e,  short  head  of  biceps  ;/,  long  head  of  biceps  ;  g,  semitendinosus  ; 
h,  semimembranosus  ;  i,  adductor  magnus  ;j,gracilis  ;  &,  adductor 
longus  ;  I,  sartorius.  1,  femoral  artery  ;  2,  great  sciatic  nerve  ; 
3,  great  saphenous  vein  ;  4,  middle  cutaneous  nerve  ;  5,  external 
cutaneous  nerve  ;  6,  perforating  branches  from  profunda ;  7, 
small  sciatic  nerve. 

force  to  the  limb  with  a  properly  graduated  sys- 
tem of  weights  and  pulleys.  It  is  doubtful  if  a 
fracture  of  the  shaft  of  the  femur  can,  after  any 
treatment,  become  united  without  some  shorten- 
ing resulting,  save  in  a  few  exceptional  cases. 
It  is  important,  in  connexion  with  this  subject, 


568  THE    LOWER    EXTREMITY 

to  remember  that  the  lower  limbs  may  be  normally 
of  unequal  length.  Dr.  Garson,  as  a  result  of 
the  careful  examination  of  some  70  skeletons, 
states  that  both  the  lower  limbs  are  of  equal 
length  in  only  about  10  per  cent,  of  all  cases. 
He  also  found  that  the  femur  was  more  frequently 
the  seat  of  variation  than  the  tibia. 

Amputation  of  the  thigh.— As  already  men- 
tioned, the  unequal  contraction  of  the  muscles 
renders  a  circular  amputation  unsuitable  for  the 
thigh.  Hence  the  operation  preferred  is  one  in 
which  a  large  flap  is  formed  from  the  tissues  in 
front  of  the  thigh,  and  a  shorter  flap  from  the 
structures  on  the  posterior  aspect.  The  various 
structures  which  are  involved  and  the  relation- 
ship of  the  one  to  the  other  are  best  understood 
by  examining  a  section  of  the,  thigh,  such  as  is 
shown  in  Fig.  127.  The  parts  cut  are  the  following : 
the  quadriceps,  sartorius,  gracilis,  long  and  great 
adductors,  and  the  three  hamstring  muscles ;  the 
superficial  and  deep  femoral  vessels,  the  descend- 
ing branches  of  the  external  circumflex  artery,  the 
lower  perforating  vessels,  and  the  long  saphenous 
vein ;  the  main  branches  of  the  femoral  nerve 
(middle  cutaneous,  internal  cutaneous,  and  mus- 
cular, together  with  the  long  saphenous  nerve), 
the  anterior  branch  of  the  external  cutaneous 
nerve,  the  obturator,  and  the  great  and  small 
sciatic  nerves. 


CHAPTER   XXIV 
THE   REGION   OF   THE   KNEE 

IN  this  chapter  will  be  considered  the  articulation 
of  the  knee,  the  soft  parts  about  the  joint,  the 
popliteal  space,  the  lower  end  of  the  femur,  the 

Eatella,    and    the    upper    ends    of    the    tibia   and 
bula. 

Surface  anatomy. — In  the  front  of  the  knee 
the  patella  can  be  distinctly  felt  and  seen.  Its 
inner  border  is  a  little  more  prominent  than  the 
outer.  When  the  limb  lies  in  the  extended  pos- 
ture, with  the  quadriceps  relaxed,  the  patella  can 
be  moved  to  and  fro,  and  appears  to  be  but  loosely 
attached.  When  the  quadriceps  is  contracted  the 
bone  is  drawn  upwards,  and  becomes  firmly  fixed 
against  the  femur.  In  flexion  of  the  joint  the 
patella  sinks  into  the  hollow  between  the  tibia  and 
the  intercondyloid  notch,  and  is  very  firmly  fixed. 
In  this  position  some  part  of  the  trochlear  surface 
of  the  femur  can  be  made  out  above  the  patella. 
On  each  side  of  the  knee-cap  a  hollow  exists  which 
may  be  completely  filled  up  with  fat  in  the  obese. 
When  the  limb  lies  in  the  extended  posture  the 
ligamentum  patellae  is  not  to  be  very  distinctly 
made  out.  It  becomes  a  little  more  conspicuous 
in  the  flexed  position,  and  is  most  prominent  when 
the  quadriceps  muscle  is  vigorously  contracted. 
The  subpatellar  pad  of  fat  bulges  outwards  on 
each  side  of  the  ligament  and  may  be  mistaken 
by  the  inexperienced  for  fluid  in  the  joint. 

On  the  inner  side  of  th©  knee  the  following  parts 

can  be  felt  from  above  downwards  (Fig.  128)  :  the 

tubercle  for  the  adductor  magnus,  and  the  tendon 

of  insertion  of  that  muscle;  the  inner  condyle  of 

569 


570 


THE  LOWER  EXTREMITY 


[CHAP. 


the  femur,  which  is  very  prominent,  and  forms 
the  chief  part  of  the  rounded  eminence  on  this 
aspect  of  the  joint;  and  below  this  the  inner 
tuberosity  (condyle)  of  the  tibia.  Between  the 
two  latter  processes  of  bone,  the  interarticular 
line  and  semilunar  cartilage  (medial  meniscus) 
are  easily  ^felt  (Fig.  128).  On  the  outer  side  of 
the  joint  is  the  external  condyle  of  the  femur, 


PREPATEL.   BURS* 
SYNOV.    MEMB. 


SUBSEMITEND.    BUHSA 


POST.  Tia.   ART 
ANT.  TIB.  ART. 


I     *  Mil    ' 

Fig.  128.— Surface  anatomy  of  the  inner  aspect  of  the 
knee-joint. 


which  is  much  less  conspicuous  than  its  fellow 
of  the  opposite  side,  and  before  it  is  the  corre- 
sponding tuberosity  of  the  tibia,  forming  a 
marked  prominence.  Immediately  in  front  of  the 
biceps  tendon  the  upper  part  of  the  external 
lateral  ligament  can  be  felt  when  the  joint  is  a 
little  flexed.  Between  the  tendon  and  the  patella 
the  lower  part  of  the  ilio-tibial  band  can  be 


REGION  OF  THE  KNEE  571 

detected  as  a  prominent  rounded  band,  descend- 
ing to  the  external  tuberosity  (condyle)  of  the 
tibia.  It  is  most  distinct  when  the  knee-joint  is 
forcibly  extended  by  muscular  action,  and  often 
stands  out  conspicuously  beneath  the  skin.  The 
tubercle  of  the  tibia  and  the  head  of  the  fibula 
are  both  readily  felt,  and  are  nearly  on  the  same 
level. 

The  popliteal  space  only  appears  as  a  hollow 
when  the  knee  is  bent.  In  the  extended  limb  the 
hollow  is  replaced  by  an  evenly  rounded  eminence. 
The  crease  in  the  skin  that  passes  transversely 
across  the  ham  is  some  way  above  the  line  of  the 
knee-joint.  On  the  outer  side  of  the  space  the 
biceps  tendon  can  be  very  readily  felt,  especially 
when  the  muscle  is  in  action.  Just  behind  it,  and 
along  its  inner  border,  lies  the  common  peroneal 
nerve.  It  can  be  rolled  under  the  finger  as  it 
crosses  the  head  of  the  fibula  to  pass  beneath  the 
peroneus  longus  muscle.  On  the  inner  side  of 
the  ham  three  tendons  can  be  felt.  Nearest  to 
the  middle  of  the  space  is  the  long,  prominent 
tendon  of  the  semitendinosus.  Internal  to  it 
is  the  larger  and  less  distinct  semimembranosus 
tendon,  and  still  more  to  the  inner  side  the 
gracilis  may  be  made  out. 

The  popliteal  vessels  enter  the  ham  obliquely 
at  its  upper  and  inner  part,  and  under  cover  of 
the  semimembranosus  muscle.  The  outer  border  of 
this  muscle  is  the  guide  to  the  upper  portion  of  the 
artery  (Fig.^128).  The  vessels  in  their  descent  reach 
a  point  behind  the  middle  of  the  knee-joint,  and 
then  pass  vertically  downwards.  The  termination 
of  the  popliteal  artery  is  on  a  level  with  the  lower 
part  of  the  tubercle  of  the  tibia.  When  the  limb 
is  flexed,  the  pulsations  of  the  artery  can  be  felt 
and  the  vessel  compressed  against  the  femur  a 
little  below  its  point  of  entry  into  the  popliteal 
space.  The  upper  articular  arteries  run  trans- 
versely inwards  and  outwards  just  above  the 
femoral  condyles.  The  lower  articular  arteries 
are  also  placed  transversely,  the  inner  vessels 


572  THE    LOWER    EXTREMITY  [CHAP. 

running  just  below  the  internal  tuberosity  of 
the  tibia,  and  the  outer  just  above  the  head  of  the 
fibula.  The  deep  branch  of  the  anastomotica 
magna  descends  to  the  inner  condyle  of  the  femur 
in  the  substance  of  the  vastus  internus,  and  along 
the  front  of  the  adductor  magnus  tendon.  The 
internal  saphenous  vein  passes  up  along  the  back 
part  of  the  internal  condyle  of  the  femur,  and 
then  follows  the  sartorius  muscle  to  the  thigh. 
It  is  just  below  the  interarticular  line  that  the 
long  saphenous  nerve  usually  joins  the  vein.  The 
short  saphenous  vein  follows  the  middle  line  of 
the  calf  just  below  the  ham,  and  pierces  the  deep 
fascia  at  the  lower  part  of  the  popliteal  space. 
This  vessel  is  much  less  conspicuous  than  is  the 
long  saphenous  vein,  and  is,  indeed,  not  often  to 
be  seen  unless  varicose. 

The  internal  popliteal  (tibial)  nerve  descends 
in  the  middle  line,  and  continues  the  line  that 
marks  the  course  of  the  great  sciatic  trunk. 

Front  of  the  knee. — The  skin  over  the  front 
of  the  knee  is  dense  and  very  movable.  This 
mobility  affords  considerable  protection  to  the 
knee-joint,  especially  in  stabs  with  bluntish  in- 
struments, and  in  any  injury  where  the  gliding 
movement  of  the  skin  may  direct  the  violence  away 
from  the  articulation.  In  flexion,  the  skin  is 
drawn  tightly  over  the  patella,  and,  as  is  the 
case  elsewhere,  where  the  integument  lies  more 
or  less  directly  upon  the  bone,  a  contusion  over 
the  knee-cap  may  produce  a  lesion  precisely  like 
an  incised  wound.  In  the  Lancet  for  1877  is 
recorded  the  case  of  a  very  stout  woman  aged  57, 
who,  stumbling  on  a  hard  road,  fell  upon  her  bent 
knee.  The  skin  was  burst  across  the  front  of  the 
knee,  and  a  wound  produced  that  was  7  inches  in 
length,  and  as  cleanly  cut  as  if  made  by  a  scalpel. 

There  is  but  little  subcutaneous  fat  in  front  of 
the  articulation,  and  thus  it  happens  that  in  am- 
putations through  the  knee-joint  the  anterior  flap 
is  very  thin,  and  is  composed  of  little  other  than 
the  simple  integument. 


xxiv]  FRONT   OF  THE  KNEE  573 

As  blisters,  and  various  forms  of  counter- 
irritant,  are  often  applied  to  the  front  of  the  knee 
in  cases  of  disease,  it  may  be  well  to*  take  note  of 
the  blood  supply  of  this  part,  and  of  the  relations 
between  the  surface  vessels  and  nerves  and  those  of 
the  joint.  The  vessels  that  give  branches  to  the 
front  of  the  knee,  and  are  concerned  in  the 
supply  of  the  part  to  which  blisters  are  usually 
applied,  are  the  anastomotic,  the  four  articular 
branches  of  the  popliteal,  and  the  anterior  tibial 
recurrent.  In  some  reflex  manner,  not  well 
understood,  a  counter-irritant  applied  to  the  skin 
over  the  joint  alters  the  nutrition  and  blood 
supply  of  the  joint  itself.  The  skin  over  the 
front  of  the  knee,  the  anterior  parts  of  the  joint, 
and  the  quadriceps  are  supplied  from  the  third 
and  fourth  lumbar  segments  through  branches 
of  the  anterior  crural  (femoral)  and  obturator 
nerves. 

The  superficial  lymphatics  in  the  region  of  the 
knee  lie  for  the  most  part  on  the  inner  aspect  of 
the  joint,  and  follow  the  course  of  the  long 
saphenous  vein.  Ulcers,  and  other  inflammatory 
affections  of  the  skin  over  the  articulation,  are 
more  apt  to  be  associated  with  lymphangitis  and 
with  enlargement  of  the  inguinal  glands  when 
situate  on  the  inner  aspect  of  the  joint  than  when 
placed  in  front  or  to  the  outer  side  of  it. 

The  bursae  over  the  front  of  the  knee  are  :  (1) 
The  patellar  bursa,  a  large  sac  placed  in  front 
of  the  patella  and  upper  part  of  the  patellar  liga- 
ment, separating  those  structures  from  the  skin 
(Fig.  128).  It  is  frequently  divided  by  septa  into 
superficial  and  deep  compartments.  It  is  very 
often  found  enlarged  in  those  who  kneel  much — 
in  housemaids,  stonemasons,  religieuses,  etc.  The 

Earts  about  are  well  supplied  with  nerves,  and 
ence  much  pain  is  e  usually  associated  with  acute 
inflammation  of  this  sac.  It  is  in  close  contact 
with  the  patella,  and,  in  one  case  reported  by 
Erichsen,  suppuration  of  the  bursa  led  to  caries 
of  that  bone.  (2)  There  is  a  bursa  between 


574  THE    LOWER    EXTREMITY  [CHAP. 

the  patellar  ligament  and  the  tubercle  of  the 
tibia  (Fig.  129).  When  inflamed,  this  causes 
more  pain  than  is  observed  in  affections  of  the 
previous  bursa,  since  it  is  firmly  compressed  be- 
tween two  rigid  structures,  the  ligament  and  the 
bone.  It  is  separated  from  the  synovial  cavity 
by  the  pad  of  fat  that  lies  behind  the  patella. 
(3)  The  bursa  between  the  quadriceps  tendon  and 
the  femur  will  be  considered  in  connexion  with 
the  synovial  cavity. 

Popliteal  space.— The  skin  over  the  space 
is  not  so  movable  as  is  that  over  the  front  of 
the  knee.  When  destroyed  by  injury,  by  burns, 
or  by  extensive  ulceration,  the  contraction  of  the 
resulting  cicatrix  may  lead  to  a  rigidly  bent 
knee.  The  skin  in  this  place  has  also  been  rup- 
tured by  forcible  extension  applied  to  the  limb  in 
cases  of  contracted  knee.  Beneath  the  skin  and 
superficial  tissue  is  the  popliteal  fascia,  a  dense 
membrane  that  covers  in  the  space.  It  is  but 
a  continuation  of  the  fascia  lata  of  the  thigh, 
and  is  continuous  below  with  the  fascia  of  the  leg. 
It  passes  without  bony  attachment  over  the  ham- 
string muscles  that  bound  the  ham.  This  fascia 
limits,  often  in  a  very  marked  manner,  the  pro- 
gress of  popliteal  abscesses  and  growths  towards 
the  surface.  Its  unyielding  character  is  a  prime 
cause  in  the  production  of  the  severe  pain  with 
which  such  collections  and  tumours  are  often 
associated.  The  popliteal  abscess,  unable  to  reach 
the  surface,  is  encouraged  to  extend  either  up 
into  the  thigh  or  down  the  leg.  The  ham  may 
hold  a  very  considerable  quantity  of  pus.  Vel- 
peau  saw  a  case  where  a  litre  (If  pints)  of  pus 
was  evacuated  from  this  region  in  a  patient 
who  presented  before  the  operation  but  an  in- 
significant swelling  in  the  site  of  the  collection. 
Duplay  records  two  cases  of  ulceration  of  an  ab- 
scess into  the  popliteal  artery,  and  Ollivier  an 
instance  where  the  abscess,  unable  to  find  a  way  to 
escape,  ultimately  entered  the  knee-joint. 

Pus  may  reach  the  ham  from  the  buttock  or 


xxiv]  HAMSTRING   MUSCLES  575 

pelvis  by  following  the  great  sciatic  nerve,  or  may 
extend  from  the  thigh  through  the  opening  in  the 
great  adductor  for  the  femoral  vessels. 

The  hamstring  muscles  and  fascial  structures 
are  frequently  found  permanently  shortened  in 
neglected  cases  of  knee-joint  disease,  and  pro- 
duce thereby  more  or  less  rigid  flexion  of  the 
leg  upon  the  thigh.  Irritation  from  disease  of 
the  knee-joint  may  lead  to  contractor e  of  the 
hamstring  muscles.  These  muscles  are  supplied 
through  the  great  sciatic  nerve  from  the  fifth 
lumbar  segment,  from  which  the  knee-joint  de- 
rives in  part  its  nerve  supply.  Contraction  of 
these  muscles  in  knee-joint  disease  tends  not  only 
to  flex  the  knee  but  also  to  draw  the  tibia 
backwards  and  produce,  in  some  cases,  a  partial 
luxation. 

The  hamstring  tendons  may  be  ruptured  by 
violence,  the  tendon  most  frequently  torn  being 
that  of  the  biceps.  The  muscles  are  greatly 
stretched  when  the  trunk  is  bent  forcibly  forwards 
at  the  hip-joint,  the  knee  remaining  extended. 
Extreme  movement  in  this  position  has  ruptured 
some  of  the  fibres  of  this  muscle.  The  difficulty 
experienced  in  touching  the  toes  with  the  fingers 
while  the  knees  are  kept  stiff  depends  upon  the 
resistance  offered  by  the  stretched  hamstrings. 
In  tenotomy  of  the  biceps  tendon  the  common 

feroneal  nerve  is  in  great  risk  of  being  wounded, 
t  may  be  noted  that  contraction  of  the  muscle 
tends  to  increase  the  distance  between  the  tendon 
and  the  nerve,  and  to  render  the  former  more 
superficial.  The  peroneal  nerve  may  be  com- 
pressed by  bandages,  garters,  or  "putties"  ap- 
plied too  tightly  over  the  head  or  neck  of  the 
fibula.  In  such  cases  there  is  a  tendency  to  trail 
the  foot  in  walking,  owing  to  a  partial  paralysis 
of  the  extensor  muscles  of  the  leg,  which  are 
supplied  by  the  two  branches  of  the  common 
peroneal  nerve. 

Vessels  of  the  ham. — The  popliteal  vessels  are, 
from  their  depth,  but  seldom  wounded.  It  must 


576  THE    LOWER    EXTREMITY          [CHAP. 

be  borne  •  in  mind  that  the  lower  part  of  the 
popliteal  artery  may  be  reached  from  the  anterior 
aspect  of  the  leg  by  an  instrument  passing  between 
the  tibia  and  fibula.  Thus,  Spence  reports  the 
case  of  a  farmer  who  received  a  wound  in  front 
of  the  leg,  just  below  the  knee,  from  the  slipping 
of  his  knife  while  cutting  a  stick.  It  was  dis- 
covered subsequently  that  the  knife  had  entered 
the  interosseous  space  and  had  wounded  the  pop- 
liteal artery  at  its  bifurcation.  It  had  indeed 
nearly  severed  the  anterior  tibial  artery  from  the 
main  trunk. 

The  popliteal  artery  has  been  ruptured  by  ex- 
ternal violence,  as  when  a  wheel  has  passed  over 
the  region  of  the  vessel.  This  artery  is  more  fre- 
quently the  seat  of  aneurysm  than  is  any  other 
artery  in  the  body,  save  only  the  thoracic  aorta. 
In  551  cases  of  spontaneous  aneurysm,  collected 
by  Crisp,  the  popliteal  vessel  was  the  seat  of  the 
disease  in  137  instances,  the  thoracic  aorta  having 
been  affected  in  175  of  the  cases.  This  marked  dis- 
position to  aneurysm  depends  upon  many  factors. 
The  vessel  is  subjected  to  a  great  deal  of  move- 
ment, which  may  readily  injure  a  popliteal  artery 
that  has  lost  its  elasticity  owing  to  age  or  disease. 
Experiments  upon  the  dead  body  show  that  the 
inner  and  middle  coats  of  the  vessel  may  be  rup- 
tured by  extreme  flexion  of  the  knee,  and  that  a 
like  rupture  may  in  a  smaller  percentage  of  cases 
be  brought  about  by  forcible  ^extension.  More- 
over, except  when  the  limb  is  in  the  position  of 
extension,  the  popliteal  artery  is,  like  the  thor- 
acic aorta,  much  curved.  Then,  again,  the  vessel 
breaks  up  into  two  large  vessels,  and  it  is  well 
known  that  the  point  of  bifurcation  of  an  artery 
is  a  favourite  spot  for  aneurysm.  Lastly,  the 
artery  is  supported  only  by  the  lax  tissue  of  the 
popliteal  space,  and  the  support  of  strong  muscles 
given  elsewhere  to  so  many  large  vessels  is  practi- 
cally absent.  Some  popliteal  aneurysms  have  been 
successfully  treated  by  flexing  the  knee  and  retain- 
ing the  limb  for  some  time  in  that  position.  That 


xxiv]  VESSELS   OF  THE   HAM  577 

flexion  can  have  a  direct  effect  upon  the  lumen  of 
the  vessel  is  shown  by  the  diminished  pulse  at 
the  inner  ankle  produced  by  forcibly  bending  the 
leg  upon  the  thigh.  The  artery  and  vein  are  so 
adherent  that  it  is  difficult  to  separate  the  two 
when  applying  a  ligature  to  the  arterial  trunk. 
This  adhesion  must  have  been  appreciated  by  any 
who  have  taken  pains  to  "  clean  "  the  artery  in  a 
dissection  of  the  ham. 

The  popliteal  vein  is  a  remarkably  substantial 
vessel,  and  has  walls  so  dense  and  thick  that  on 
section  they  often  look  more  like  the  tunics  of  an 
artery.  On  the  ground  of  this  peculiarity,  and  of 
its  close  adhesion  to  its  companion  vessel,  Tillaux 
asserts  that  "  it  is  unlike  any  other  vein  in  the 
economy."  It  is  worthy  of  note  that  the  vein, 
although  more  superficial  than  the  artery,  is  very 
rarely  ruptured  by  violence.  As  a  rule,  the  artery 
alone  is  torn. 

From  the  relations  of  the  artery  to  the  vein 
and  nerve  it  will  be  understood  that  the  popliteal 
aneurysm  may  soon  lead  to  oedema  of  the  leg  and 
to  nerve  symptoms  depending  upon  pressure  on 
the  internal  popliteal  trunk.  It  has  more  than 
once  also  made  its  way  into  the  knee-joint,  with 
the  posterior  ligament  of  which  the  artery  is  in 
such  close  relation. 

The  short  or  small  saphenous  vein  lies  almost  in 
the  middle  line,  and,  not  being  usually  apparent 
through  the  skin,  may  be  divided  in  an  inci- 
sion made  into  the  lower  part  of  the  popliteal 
space. 

The  lymphatic  glands  in  the  ham  are  from 
four  to  five  in  number  and  are  deeply  placed 
about  the  great  vessels.  When  enlarged  they  have 
been  mistaken  for  aneurysm  and  other  popliteal 
tumours.  They  receive  the  deep  lymphatics  of 
the  outer  and  posterior  aspects  of  the  foot  and 
leg.  A  small  gland  is  often  met  with  beneath 
the  fascia,  close  to  the  point  of  entry  of  the  short 
saphenous  vein.  It  receives  some  lymphatics  that 
follow  that  vessel. 


578  THE    LOWER    EXTREMITY          [CHAP. 

The  bursae  about  the  ham  are  usually  seven 
in  number,  four  on  the  inner  side  of  the  space 
and  three  on  the  outer.  Inner  side. — (1)  A  large 
bursa  beneath  the  semimembranosus  and  over  the 
internal  condyle  of  the  femur  and  the  inner  head 
of  the  gastrocnemius  (Fig.  128).  This  is  the  largest 
bursa  in  the  space,  and  after  adult  life  it  usually 
communicates  with  the  -joint.  It  is,  of  all  the 
bursse  in  this  region,  the  one  most  often  enlarged, 
and  when  affected  may  attain  great  size.  In  one 
reported  case  the  sac  measured  5  by  3|  inches. 
In  the  extended  position  of  the  limb  the  enlarged 
bursa  feels  firm  and  resistant,  but  on  flexion  it 
becomes  flaccid  and  can  often  be  made  entirely  to 
disappear.  Probably  the  slit-like  communication 
between  the  bursa  and  the  joint  is  closed  when 
the  posterior  ligament  is  tightened  by  extension, 
and  is  opened  when  it  is  relaxed  on  bending  the 
knee.  In  the  latter  posture  the  contents  of  the 
bursa  can  be  reduced  into  the  cavity  of  the  knee- 
joint,  and  so  the  tumour  disappears.  (2)  A  little 
bursa  between  the  semimembranosus  tendon  and 
the  internal  tuberosity  of  the  tibia.  Rather  below 
the  level  of  the  knee  there  are  two  further  bursse — 

(3)  one  beneath  the  insertion  of  the  sartorius,  and 

(4)  another  beneath  the  insertions  of  the  gracilis 
and    semitendinosus.      Outer    side. — (1)    A    large 
diyerticulum   of    the    synovial    membrane    of   the 
joint  between  the  popliteus  tendon   and   the   ex- 
ternal tuberosity  of  the  tibia.     This  diverticulum 
serves  the  purpose  of  a  bursa,  and  may  open  into 
the  tibio-tibular   articulation,   and  so  bring  that 
cavity  into  connexion  with  the  knee-joint.     (2)  A 
bursa  between  the  outer  head  of  the  gastrocnemius 
and  the  outer  femoral  condyle.     It  is  not  constant 
and  is  not  connected  with  the  articulation.     (3)  A 
bursa  between  the  biceps  tendon  and  the  external 
lateral  ligament.     The  peroneal  nerve  runs  across 
this  sac — a  circumstance  that  may  explain  some  of 
the  pain  experienced  when  the  bursa  is  enlarged. 

It  is  not  improbable  that  wounds  in  this  region 
of  bursse  containing  fluid  have  been  mistaken  for 


xxivj  THE   KNEE-JOINT  579 

wounds  of  the  joint,  and  the  escaping  serum  for 
synovia. 

The  knee-joint  (Fig.  129).— This  articulation 
is  the  largest  in  the  body.  It  owes  its  great 
strength  to  the  powerful  ligaments  that  unite  the 
two  component  bones,  and  especially  to  the  mus- 
cles and  fasciae  that  surround  it.  It  derives  no 
strength  from  the  shape  of  the  articular  surfaces, 
since  they  are  merely  placed  in  contact  with  one 
another.  In  spite  of  its  frequent  exposure  to  in- 
jury, dislocations  at  the  knee  are  extremely  rare. 
The  lateral  ligaments  are  comparatively  feeble, 
are  tense  in  extension  and  relaxed  in  flexion. 
The  laxity  of  these  ligaments  is  such  that  partial 
luxations  of  the  tibia  are  possible  without  rup- 
ture of  these  bands,  especially  in  cases  where  the 
joint  is  found  slightly  flexed  after  the  accident. 
The  crucial  ligaments  are  very  powerful,  and 
are  more  or  less  tense  in  all  extreme  positions 
of  the  joint.  The  anterior  of  these  ligaments 
especially  resists  extension,  forward  displace- 
ment of  the  tibia,  and  rotation  inwards  of 
the  leg.  The  posterior  ligament  resists  extreme 
flexion  and  displacement  backwards  of  the  tibia. 
In  the  movement  of  extension  the  tibia  slides 
a  little  forwards  and  is  rotated  a  little  out- 
wards. In  flexion  that  bone  glides  backwards  and 
rolls  a  little  inwards.  Extension  generally  is 
limited  by  the  crucial  and  posterior  ligaments; 
flexion  by  the  ligamentum  patellae  and  anterior 
part  of  the  capsule,  in  addition  to  the  crucial 
ligaments.  Rotation  is  possible  only  in  the  flexed 
position.  The  thinnest  part  of  the  posterior  liga- 
ment is  the  portion  below  the  oblique  fibres  de- 
rived from  the  semimembranosus.  If  pus  should 
find  its  way  from  the  joint  into  the  ham,  it 
will  probably  escape  through  this  part  of  the 
ligament. 

In  the  contracted  knee  associated  with  fibrous 
ankylosis  the  chief  contraction,  so  far  as  the 
joint-tissues  are  concerned,  is  in  the  posterior 
ligament,  in  the  lateral  ligaments,  and  in  the 


580  THE    LOWER    EXTREMITY          [CHAP. 

fibrous  and  fatty  tissue  between  the  former  liga- 
ment and  the  posterior  crucial  band.  But  it  must 
be  kept  in  mind  that  all  structures  are  affected— 
the  skin,  the  aponeuroses,  and  particularly  the 
muscles. 

The  synovial  membrane  of  the  knee-joint  ex- 
tends upwards  as  a  large  cul-de-sac  above  the 
patella  and  beneath  the  extensor  tendon.  This 
cul-de-sac  reaches  a  point  an  inch  or  more  above 
the  upper  margin  of  the  trochlear  surface  of  the 
femur,  and  is  rendered  very  distinct  when  the 
joint  is  distended  with  fluid  (Fig.  129).  When 
the  knee  is  bent  the  cul-de-sac  is  drawn  down, 
and  therefore  this  position  of  the  limb  is  advised 
when  operations  are  about  to  be  performed  upon 
the  lower  end  of  the  femur.  Above  the  synovial 
pouch  is  a  bursa  that  separates  the  quadriceps 
tendon  from  the  femur,  and  is  usually  over  an 
inch  in  its  vertical  measurement  (Fig.  129).  From 
the  examination  of  260  knee-joints  in  both  infants 
and  adults,  Schwartz  found  that  this  bursa  com- 
municated with  the  synovial  cavity  in  7  cases 
out  of  10  in  young  children,  and  in  8  cases  out 
of  10  in  adults.  It  will  thus  be  seen  that,  when 
this  communication  exists,  a  stab  over  the  femur, 
about  2  inches  above  the  trochlear  surface  of  the 
bone,  or  about  the  same  distance  above  the  top 
of  the  patella,  when  the  limb  is  extended,  will 
practically  open  the  knee-joint. 

The  complexity  of  the  synovial  membrane  in 
the  knee-joint  is  due  to  the  fact  that  there  are 
really  three  subcompartments  or  joint-cavities. 
These  are — (1)  the  trochlear,  for  movements  of 
the  patella;  (2)  the  external  tibio-femoral ;  (3) 
the  internal  tibio-femoral.  The  two  latter  are 
subdivided  by  the  semilunar  cartilages  (articular 
menisci)  into  upper  and  lower  compartments.  In 
the  upper  compartments  the  rolling  condylar 
movements  occur;  in  the  lower,  the  gliding  move- 
ments between  the  menisci  ^  and  the  tibia.  In 
walking,  movements  occur  in  all  five  compart- 
ments. The  ligamentum  mucosum  lies  between 


xxiv]         LIGAMENTS   OF   KNEE  JOINT 


581 


the   trochlear    and    condylar    joints;    the    crucial 
ligaments  between  the  tibio-femoral  joints. 

The  crucial  ligaments,  although  more  or  less 
completely  invested  by  the  synoyial  membrane, 
are  yet  entirely  outside  the  synovial  cavity.  The 
posterior  crucial  ligament  is  continuous  with  the 
posterior  part  of  the  capsule. 


-a 


Fig.  129.— Vertical   section  of  knee-joint  distended  with 
fluid.     (Braune.} 

a,  Vastus  externus  ;  b,  crureus ;  c,  short  head,  and  d,  long  head,  of 
biceps  ;  e,  plantaris  ;  /,  gastrocnemius  ;  g,  popliteus  ;  h,  soleus ; 
z,  tibialis  posticus  ;  j,  bursa  patellae  ;  k,  ligamentum  patellae ; 
I,  ligamentum  mucosum  ;  m,  anterior  crucial  ligament ;  w,  exter- 
nal semilunar  cartilage.  1,  external  popliteal  nerve  ;  2,  popliteal 
artery 

The  upper  third  of  the  patellar  ligament  is  in 
relation  to  the  synovial  membrane  of  the  patellar 


582  THE    LOWER    EXTREMITY  [CHAP. 

joint,  from  which,  however,  it  is  separated  by  a 
pad  of  fat.  The  lower  two-thirds  of  the  ligament 
are  in  relation  to  the  bursa  and  fatty  tissue  that 
intervene  between  the  band  and  the  tibia.  A  knife 
passed  horizontally  backwards  at  the  apex  of  the 
patella  would,  when  the  limb  is  extended,  just  miss 
the  joint-line  between  the  femur  and  tibia,  and 
would  hit  the  latter  bone.  If,  however,  there  be 
any  effusion  in  the  joint,  or  the  limb  be  a  little 
flexed,  a  knife  so  introduced  would  pass  between 
the  two  bones  (Fig.  129).  Fringes  of  the  synovial 
membrane  (the  alar  ligaments)  fill  the  intervals 
between  the  articular  surfaces  of  the  patella  and 
femur.  Villous  processes  may  grow  out  from 
them,  become  detached,  and  form  loose  bodies  in 
the  joint.  That  such  processes  should  undergo 
chondrification  and  form  cartilaginous  bodies  is 
not^  surprising,  seeing  that  the  synovial  lining  is 
derived  from  the  same  tissue  as  forms  the  articular 
surfaces  of  the  bones  and  is  in  reality  merely  a 
finely  spread  layer  of  cartilage  covering  a  fibrous 
membrane 

Joint  -  disease. — Owing  to  its  superficial  posi- 
tion the  knee-joint  is  the  articulation  that  is 
most  frequently  the  seat  of  inflammation  due  to 
injury  and  exposure  to  cold.  When  distended 
with  fluid,  the  effusion  soon  shows  itself  above 
and  at  the  sides  of  the  patella,  by  bulging  for- 
ward the  synovial  sac,  which  is  here  more  nearly 
in  relation  to  the  surface  than  it  is  elsewhere. 
Fluctuation  is  soon  to  be  detected,  and  the  patella, 
being  pushed  away  from  the  femur,  is  said  to 
"float"  upon  the  distending  fluid  (Fig.  129). 

The  inflamed  knee-joint,  if  left  to  itself,  almost 
invariably  assumes  the  flexed  position.  This  is 
the  position  of  rest;  the  muscles  are  here  relaxed 
and  do  not  press  the  joint-surfaces  together;  the 
ligaments  are  no  longer  tense,  and  the  fluid- 
capacity  of  the  joint  is  increased. 

Dislocation  of  the  semilunar  cartilages  or  menisci. 
— One  or  other  of  these  cartilages  may  be  dis- 
placed from  its  attachments  to  the  tibia,  and 


xxiv]  DISLOCATION   OF  MENISCI  583 

become  nipped  or  locked  between  that  bone  and 
the  femur.  The  accident  is  particularly  common 
in  miners  who  work  in  a  crouched  posture,  and 
in  all  who  take  part  in  vigorous  games  and 
exercises.  The  result  is  a  sudden  pain  in  the 
limb,  often  associated  with  a  fixing  of  the  knee 
in  a  flexed  position.  The  accident  is  usually 
brough^  about  by  a  twist  given  to  the  leg  when 
the  knee-joint  is  more  or  less  bent,  but  it  may 
occur,  as  Walton  maintains,  even  in  extreme 
extension.  The  effective  cause  is  a  twisting  of 
the  joint  so  that  the  condyles  of  the  femur  and 
tuberosities  of  the  tibia  rotate  in  opposite  direc- 
tions. In  200  cases  of  internal  derangement  of 
the  knee-joint,  Bennett  found  that  the  internal 
cartilage  was  affected  in  155  cases  and  the  external 
in  only  45.  The  left  knee  was  the  seat  of  derange- 
ment nearly  three  times  as  often  as  the  right,  and 
the  lesion  occurred  nine  times  more  frequently  in 
men  than  in  women.  The  anterior  extremity  of 
the  internal  semilunar  cartilage  is  usually  found 
bruised  and  torn  from  its  tibial  attachment.  To 
understand  the  liability  to  injury  of  the  anterior 
part  of  the  internal  semilunar  cartilage,  it  is 
necessary  to  examine  the  manner  in  which  it  is 
maintained  in  position,  the  movements  which  it 
undergoes,  and  the  strains  to  which  it  is  sub- 
jected in  active  athletes.  In  the  extended  position 
of  the  knee,  displacement  is  less  easy,  for  the 
cartilages  are  immovably  fixed  by  the  coaptation 
of  the  articular  surfaces,  brought  about  by  the 
tension  of  the  ligaments  and  active  contraction 
of  the  muscles  surrounding  the  joint.  When 
the  joint  is  partly  flexed  the  internal  cartilage  is 
fixed  (1)  by  its  anterior  horn  attached  to  the  tibia, 
above  and  behind  the  attachment  of  the  liga- 
mentum  patellae  and  outside  the  joint-cavity  (Fig. 
130) ;  (2)  by  the  transverse  ligament  to  the  anterior 
part  of  the  external  cartilage  (Fig.  130) ;  (3)  by 
the  coronary  ligament  to  the  capsule  of  the  joint 
and  internal  lateral  ligament  :  the  anterior  fibres 
of  this  ligament  are  the  longest  (Fig.  130).  As 


584  THE    LOWER    EXTREMITY  [CHAP. 

the  joint  is  flexed  the  cartilages,  especially  the 
internal,  glide  backwards;  if  in  this  position  the 
biceps  brings  about  a  sudden  rotation  outwards 
of  the  tibia,  the  anterior  horn  is  carried  forwards 
and  outwards  with  that  bone,  while  the  posterior 
is  firmly  fixed  to  the  internal  condyle  of  the 
femur  by  the  internal  lateral  ligament,  and  thus 
a  severe  strain  is  thrown  on  the  anterior  part 
of  the  internal  cartilage,  which  is  brought  into 
the  position  shown  in  Fig.  130.  The  same  strain 
occurs  when  the  foot  and  tibia  are  fixed  arid  there 
takes  place  an  inward  rotation  of  the  femur,  such 

Fig.   130. — Illustrating  the  fixation  and  movements  of  the 
semilunar  cartilages. 

The  position  of  the  internal  semilunar  cartilage,  when  the  tibia  is 
rotated  outwards  or  femur  inwards,  is  shown  in  red. 

as  occurs  at  the  completion  of  extension.  The 
weakest  point  in  the  internal  semilunar  cartilage 
is  in  the  thin  inner  crescentic  margin  of  its  an- 
terior third,  and  it  is  here  that  partial  rupture 
usually  occurs.  The  intense  pain  is  due  to  the 
rupture  and  to  the  fact  that  the  strain  wedges 
the  cartilage  between  the  tibia  and  femur,  thus 
forcing  them  apart  and  causing  an  instant  and 
severe  hyperextension  of  the  unyielding  liga- 
ments of  the  joint.  The  external  cartilage  is 
smaller  than  the  internal,  is  rounder,  is  more 
movable,  and  possibly  on  these  accounts  is  less 
likely  to  be  "nipped"  between  the  bones.  It  is 


xxiv]  GENU  VALGUM  585 

attached  in  part  to  the  femur  through  the  pos- 
terior crucial  ligament,  and  is  grooved  by  the 
tendon  of  the  popliteus,  two  factors  which  add 
to  its  security  (Fig.  130).  It  is  a  remarkable 
fact  that  such  damaged  cartilages  may  be  excised 
and  yet  the  joint  may  regain  its  full  security 
of  movement. 

Genu  valgum,  or  knock-knee. — The  appearances 
produced  by  this  affection  are  familiar.  When 
a  person  stands  erect  with  the  feet  together, 
the  tibiae  are  practically  vertical,  and  the  femora 
meet  them  at  a  certain  angle,  the  tibio-femoral 
angle.  The  degree  of  this  angle  depends,  in 
normal  subjects,  to  a  great  extent  upon  the 
relative  width  of  the  pelvis.  In  genu  valgum 
this  angle  becomes  more  marked ;  the  tibiae  cease 
to  be  vertical  in  the  erect  position;  their  lower 
ends  deviate  more  and  more  from  the  middle 
line,  until  the  distance  between  the  two  malleoli 
becomes  considerable  when  the  individual  stands 
upright  and  when  he  is  not  concealing  any  of 
the  deformity  by  rotating  the  limb. 

To  understand  the  production  of  the  condition 
of  genu  valgum  we  must  first  clearly  appreciate 
the  action  of  the  muscles  which  descend  on  the 
inner  or  medial-  aspect  of  the  knee-joint — the 
semimembranosus,  semitendinosus,  gracilis,  and 
sartorius.  The  moment  that  the  erect  posture  is 
assumed  these  muscles  pass  into  a  state  of 
tonus  or  contraction,  while  the  quadriceps  ex- 
tensor becomes  lax.  These  medial  knee-supporting 
muscles  suspend  the  tibia  from  the  pelvis,  so 
that,  in  standing,  the  knees  are  braced  and  the 
weight  of  the  body  is  partly  supported  by  these 
muscular  straps.  The  first  step  in  the  pro- 
duction of  genu  valgum  lies  in  a  defective  action 
— an  exhaustion — of  the  general  postural  muscles, 
with  the  result  that  (1)  a  strain  is  thrown  on 
the  internal  lateral  ligament;  (2)  there  is  a 
tendency  to  the  production  of  a  gap  between  the 
internal  femoral  condyle  and  the  tibia!  tuberosity. 
The  pressures  on  the  joint-surfaces  are  altered, 
T* 


586 


THE    LOWER    EXTREMITY 


[CHAP. 


and  with  that  alteration  results  a  change  in  the 
growth  of  the  bones  in  the  neighbourhood  of 
the  joint,  for  the  growth  of  every  bone  is  regu- 
lated, according  to  Wolff's  law,  by  the  pressures 
falling  on  that  bone.  Hence  the  overgrowth  of 
the  inner  femoral  condyle  and  tibial  tuberosity 
when  the  pressure  is  taken  away  from  them  by 
the  failure  of  the  internal  supporting  muscles. 
In  the  young  the  overgrowth  takes  place  at  the 
adjoining  parts  of  the  epiphyseal  lines,  which 
assume  an  oblique  position.  The  overgrowth  is  on 


Fig.  131. — A,  Normal  femur.  B,  Femur  in  an  advanced 
state  of  knock-knee,  showing  the  enlargement  of  the 
internal  condyle. 

The  dotted  line  in  each  case  represents  the  line  of  the  epiphysis. 

the  shaft  side,  not  the  condylarside,  of  the  epiphy- 
seal lines  (Fig.  131).  There  is  no  alteration  in  the 
front-to-back  length  of  the  condyles;  hence,  when 
the  knee  is  flexed  the  deformity  disappears. 

Fractures  of  the  patella. — This  bone  is  more 
often  broken  by  muscular  violence  than  is  any 
other  in  the  body.  Although  the  patella  may 
be  fractured  both  by  muscular  and  by  direct 
violence,  it  would  appear  that  the  former  is  the 
agent  that  the  more  often  produces  the  lesion. 
Thus,  in  127  cases  of  simple  transverse  fracture 
collected  by  Hamilton,  he  considers  that  muscular 
action  was  the  cause  of  the  injury  in  106  in- 


xxiv]  FRACTURES   OF   PATELLA  587 

stances.  The  form  of  fracture  due  to  muscular 
violence  is  very  uniform.  It  is  nearly  always 
transverse,  simple,  and  through  the  centre  of  the 
bone,  or  just  above  that  point  or  just  below 
it.  The  position  of  the  knee  that  most  favours 
fracture  by  muscular  action  is  that  of  flexion. 
When  the  knee  is  bent,  the  patella  rests  upon 
the  femoral  condyles  along  its  transverse  axis 
only.  Nearly  the  whole  of  its  upper  half  is  un- 
supported behind,  and  the  extensor  muscle  acts 
in  a  line  nearly  at  right  angles  to  the  vertical 
axis  of  the  bone.  Thus, 
by  violent  contraction  of 
the  quadriceps,  the  patella 
may  be  snapped  across 
the  condyle  as  a  stick  is 
snapped  across  the  knee 
(Fig.  132).  As  the  fracture 
usually  causes  the  patient 
to  fall,  it  has  been  supposed 
that  the  contact  with  the 
ground,  rather  than  any  p.  132._Diagram '  to 
previous  muscular  action,  show  mechanism  of 
may  have  caused  the  lesion.  fracture  of  the  patella 
But,  as  Hamilton  has  by  muscular  action, 
pointed  out  if  a  person  rt,  Line  of  action  of  quadri. 

tails     upon     tno     bent     Knee        ceps  muscle ;  &,  femur ;  c, 

when  the  limb  also  is  flexed      tibia- 

upon    the    trunk,    the    j)art 

that  comes  in  contact  with  the  ground  is  not  the 

patella,  but  the  tubercle  of  the  tibia. 

In  the  great  majority  of  cases  the  lesion  not 
only  involves  the  bone  but  also  the  cartilage  and 
fibrous  structures  that  cover  it  respectively  behind 
and  in  front ;  the  synovial  membrane  also  is  torn, 
and  the  patella  bursa  opened  up.  Thus  the  synovial 
contents  may  come  in  actual  contact  with  the  skin. 
In  all  cases  where  there  is  much  separation  of 
the  fragments,  the  fibrous  expansion  attached  to 
either  side  of  the  patella  must  be  torn  through. 
Indeed,  none  but  a  slight  separation  of  the  parts 
is  possible  until  that  expansion  is  ruptured 


588 


THE    LOWER   EXTREMITY 


[CHAP. 


Braunc  has  demonstrated  this  by  experiment,  by 
sawing  through  the  patella  without  damage  to 
the  lateral^  ligamentous  structures,  and  noting 
that  but  trifling  separation  of  the  fragments  was 
possible  until  these  structures  had  been  divided. 
In  stellate  fractures,  due  to  direct  violence,  these 

fibrous  expan- 
sions from  the 
extensor  tendon 
may  be  unin- 
jured, and  no 
separation  of 
any  magnitude 
be  permitted  be- 
tween the  por- 
tions of  the 
broken  bone. 

The  patella  is 
more  readily 
broken  by  mus- 
cular violence 
than  is  either 
the  extensor  ten- 
don or  the  liga- 
mentum  patellae. 

Fig.  133.— Transverse  section  of  left      In      the      flexed 
knee-joint    through  the  centre 
of  the  patella.     (JBraune.) 


position  it  will 
be  seen  (Fig. 
132)  that  the 
bone  is  placed 
at  a  consider- 
able disadvan- 
tage when  com- 
pared with  the 
two  other  struc- 
tures. Richet  reports  a  case  where  violent  con- 
traction of  the  quadriceps  caused  the  tubercle  of 
the  tibia  to  be  torn  away  from  the  bone  without 
any  other  lesion  of  the  parts  immediately  con- 
cerned being  produced. 

The   patella   may   be   congcni tally    absent.      It 
is  developed  in  the  tendon  of  the  quadriceps,  re- 


rt,  Bursa  patellae  ;  b,  internal  lateral  liga- 
ment and  inner  condyle  ;  c,  external 
lateral  ligament  and  outer  condyle ; 
d,  biceps ;  e,  semimembranosus  ;  /, 
semitendinosus ;  g,  gracilis  tendon ; 
h,  sartorius.  1,  internal  popliteal 
nerve ;  2,  external  popliteal  nerve  ; 
3  internal  sapbenous  vein. 


xxiv]  DISLOCATION   OF  PATELLA  589 

maining  cartilaginous  until  the  end  of  the  second 
year.  Its  sesamoid  nature  is  seen  in  the  tendency 
to  unite  by  fibrous  rather  than  by  bony  union 
after  fracture.  It  receives  its  blood  supply  from 
nearly  all  the  arteries  round  the  knee-joint. 

Dislocation  of  the  patella. — This  bone  may  be 
dislocated  outwards  or  inwards,  or  turned  upon 
its  edge  so  that  its  anterior  and  posterior  surfaces 
are  placed  laterally.  The  luxation  outwards  is 
by  far  the  most  common.  This  depends  upon  the 
fact  that  the  quadriceps,  the  patella,  and  the 
ligamentum  patellae  do  not,  when  the  muscle 
is  contracted,  follow  the  lines  of  the  femur 
and  tibia.  They  are  more  nearly  in  a  straight 
line,  that  passes  to  the  outer  side  of  the  angle 
formed  by  the  femur  with  the  leg  at  the  knee- 
joint.  Muscular  contraction,  therefore,  tends  to 
draw  the  knee-cap  outwards,  a  tendency  that  is 
in  all  normal  circumstances  corrected  by  the  in- 
creased prominence  of  the  external  condyle.  The 
vastus  extern  us  also  is  said  to  be  more  powerful 
than  the  internus,  or  the  vastus  internus  may 
be  partially  paralysed  (D.  Greig).  The  tensor 
fasciae  femoris  has  an  attachment  to  the  patella 
through  the  ilio-tibial  band.  By  the  sudden  action 
of  this  muscle  a  patient  of  Mr.  Rigby's  was  able 
to  produce  a  voluntary  outward  dislocation  of 
the  patella.  Dislocations  usually  occur  in  the 
extended  position  of  the  joint,  and  are  commonly 
due  to  muscular  action. 

In  dislocations  of  the  knee,  which  are  very 
rare,  the  tibia  may  be  displaced  outwards,  in- 
wards, forwards,  or  backwards.  The  two  lateral 
luxations  appear  to  be  more  common  than  the 
antero-posterior.  X-ray  examination  of  such  dis- 
located joints  shows  that  the  tibial  spine  may 
be  broken,  or  detached  with  the  tibial  inser- 
tion of  a  crucial  ligament.  The  projection  of 
the  spine  of  the  tibia  between  the  femoral 
condyles  offers  an  obstacle  to  lateral  disloca- 
tion. The  former  are  nearly  always  partial,  the 
latter  usually  complete.  Considerable  violence 


590  THE    LOWER    EXTREMITY  [CHAP. 

is  required  to  produce  these  luxations,  owing 
to  the  great  strength  of  the  ligaments  and 
muscles  and  the  great  width  of  the  bones  in- 
volved. Direct  violence  to  the  tibia  or  femur, 
associated  often  with  a  twisting  of  the  former 
bone,  is  the  common  cause  of  the  lesion.  It 
is  probable  that  in  all  luxations  of  the  knee 
the  crucial  ligaments  are  torn.  The  lateral  liga- 
ments also  are  usually  ruptured,  but  in  the 
partial  luxations  they  may  be  sometimes  found 
to  be  intact.  The'  tendinous  expansion  of  the 
vasti  in  front  of  the  knee  seldom  escapes  some 
laceration,  even  in  the  partial  dislocations.  Dr. 
F.  S.  Mackenzie  found  by  experiment  on  the 
dead  body  that  division  of  the  crucial  ligaments 
did  not  materially  influence  the  force  necessary 
to  produce  a  dislocation  at  the  knee-joint.  He 
found,  too,  that  in  seven  out  of  eight  experiments 
dislocation  was  produced  and  not  fracture— 
whereas  in  life  fracture  is  by  far  the  commoner 
result.  He  concludes,  therefore,  that  the  strength 
of  the  joint  depends  on  the  surrounding  muscles 
rather  than  on  the  surrounding  ligaments.  The 
popliteal  vessels  and  nerves  are  much  compressed, 
and  appear  to  be  more  severely  injured  by  the 
femur  in  the  forward  dislocation  than  by  the 
tibia  in  the  backward  displacement. 

Lower  end  of  the  femur. — The  condylar  part 
of  the  femur  is  composed  almost  wholly  of 
cancellous  bone,  with  but  a  slight  layer  of  com- 
pact tissue.  It  is  so  spongy  that  it  may  be 
pierced  by  a  bullet,  as  pointed  out  by  Legouest, 
without  any  splintering  of  the  bone  being  pro- 
duced and  without  damage  to  the  articulation. 
The  fractures  that  may  be  met  with  in  the  lower 
end  of  the  bone  are  the  following  :  (1)  a  fracture 
of  the  shaft  above  the  condyles;  (2)  a  separation 
of  the  lower  epiphysis;  (3)  a  fracture  separating 
either  the  outer  or  inner  condyle;  (4)  a  T-shaped 
fracture,  i.e.  a  transverse  fracture  above  the  con- 
dyles with  a  vertical  one  between  those  processes. 
Those  lesions  are,  as  a  rule,  due  to  well-localized 


xxiv]  FRACTURES   OF  FEMUR  591 

direct  violence.     Fractures  Nos.   1  and  4  may  be 
produced  by  indirect  violence,  as  by  a  fall  upon 
the  feet  from  a  height.     Sir  Henry  Morris  states 
that  lateral  flexion,  or  force  applied  in  a  lateral 
direction,  is  best  calculated  to  produce  a  separa- 
tion of  the  epiphysis.    Hamilton  reports  a  strange 
case  in  a  man  aged  21,  whose  outer  condyle  was 
fractured  by  a  twist  of  the  leg  which  happened 
while  he  was  undressing  himself  to  bathe.     The 
only  fracture  that  requires  special  notice  in  this 
place  is  the  fracture  of  the  shaft  just  above  the 
condyles.     The  lesion  is  situated  generally  about 
2  inches  above  the  line  of  the  epiphysis,  and  corre- 
sponds to  the  spot  where  the  compact  shaft  joins 
the  softer  and  more  cancellous  tissue  of  the  lower 
end  of  the  bone.     It  is  near  the  place,  also,  where 
the  femoral  artery  crosses  the  bone  to  reach  the 
ham,    and   it  has   thus  happened  that  the   vessel 
has  been  wounded  by  splinters  in  this  particular 
injury.     The  fracture  is  usually  oblique,  from  be- 
hind downwards  and  forwards.     The  lower  frag- 
ment will  be  drawn  upwards  by  the  same  muscles 
that  produce  shortening  in  other  fractures  of  the 
shaft  (p.   550),   and  its  sharp   upper  end  is  very 
apt  to  be  pulled  forcibly  into  the  popliteal  space 
by  the  gastrocnemius  muscle.  This  latter  displace- 
ment is   difficult  to   remedy.     If  the  limb  be  ex- 
tended, the  fragment  is  only  drawn  the  more  into 
the    ham,    and    it    is    therefore    possible    for    the 
limb  to  appear  straight  and  yet  have  the  knee- 
joint   much   bent.      The   contraction    of   the   gas- 
trocnemius tends  to  maintain  the  lower  femoral 
fragment   in   the   popliteal   space,    and   therefore 
division    of    the    tendo    Achillis    (calcaneus)    has 
been    proposed.    -  The    reflex    contraction    of    the 
opposing  muscles  may  be  overcome  by  the  appli- 
cation of  a  continuous  traction  to  the  limb.     The 
lower    fragment   of   the    femur   may   be    replaced 
by    completely    flexing    the    leg    on    the    thigh. 
(Hutchinson  and  Barnard.) 

The   upper   end   of  the  tibia  is  sometimes  the 
seat   of  fracture,    although   of    all    parts   of   this 


592  THE    LOWER    EXTREMITY  [CHAP. 

bone  the  upper  third  is  the  part  least  often 
broken.  One  or  other  of  the  tuberosities  may  be 
broken  off,  or  there  may  be  a  transverse  or  oblique 
fracture  of  the  upper  end  of  the  shaft  associated 
with  a  vertical  one  running  up  into  the  joint  be- 
tween the  two  tuberosities.  Such  accidents  are  the 
result,  in  nearly  every  instance,  of  great  direct 
violence.  Mr.  Makins  reports  three  cases  of 
separation  of  the  anterior  tubercle  in  adolescents, 
and  many  other  cases  have  been  reported  more 
recently.  It  is  usually  ossified  by  an  extension 
from  the  epiphyseal  centre  for  the  upper  ex- 
tremity of  the  tibia,  but  may  have  a  separate 
centre  (Schlatter). 

The  spongy  tissue  in  the  head  of  this  bone  and 
in  the  lower  end  of  the  femur  is,  par  excellence, 
the  favourite  seat  for  myeloid  sarcoma. 

In  exploring  the  knee=joint  Sir  Robert  Jones 
first  flexes  the  joint  over  the  end  of  the  operating- 
table,  .  and  as  far  as  possible  maintains  it  so, 
for,  if  moved,  air  is  sucked  into  the  joint  and 
may  bring  infection  with  it.  He  opens  the  joint 
by  a  vertical  incision  which  divides  the  patella 
and  ligamentum  patellae  into  right  and  left 
halves.  This  is  the  transpatellar  route  to  the 
joint-cavity. 

In  excising  the  knee-joint  through  a  horseshoe 
incision  commencing  at  the  back  of  one  condyle, 
and  continued  across  the  joint,  above  the  insertion 
of  the  ligamentum  patellae,  to  the  back  of  the  other 
condyle,  the  following  structures  are  divided  : 
Skin,  fascia,  patellar  plexus  of  nerves  (formed 
by  the  middle  and  internal  cutaneous  and  the 
patellar  branch  of  the  long  saphenous),  bursa 
patellae,  anterior  part  of  the  capsule,  ligamen- 
tum patellae,  synovial  membrane,  lateral  and 
crucial  ligaments,  the  superior  and  inferior  ar- 
ticular arteries,  the  anastomotica  magna,  and 
the  anterior  tibial  recurrent  vessels. 

The  incision  over  the  inner  condyle  need  not 
fee  made  so  far  back  as  to  divide  the  internal 
saphenous  vein  and  nerve.  In  sawing  the  fem]ur 


xxiv] 


EXCISION  OF  KNEE-JOINT 


593 


it  is  most  important  that  the  exact  inclination 
of  the  joint-surface  of  the  bone  be  reproduced. 
If  it  were  improperly  sawn,  the  patient  would  be 
bow-legged  or  knock-kneed.  The  rule,  therefore,  is 
that  the  saw  be  applied  parallel  to  the  articular 
surface  and  perpendicular  to  the  shaft. 

In  young  subjects  care  must  be  taken  that  the 


SlJBCHURFAL     BURSA 


JOINT    CAVITY 
LIQ.   Mucos. 

SUBPATEL.   BURSA 


EPIPHYSEAL  LINES 


Fig.  134.  —  Epiphyseal  lines  in  the  neighbourhood  of  the 
knee-joint  and  their  relationship  to  the  synovial  mem- 
brane. (After  Allen  Thomson.) 

saw-cuts  do  not  pass  beyond  the  epiphyseal  line. 
The  upper  limit  of  the  femoral  epiphysis  will  be 
represented  by  a  horizontal  line  drawn  across  the 
bone  at  the  level  of  the  tubercle  for  the  adductor 
magntis  (Fig.  134).  If  the  whole  of  the  trochlear 
surface  be  removed  in  the  excision  the  whole  of  the 
epiphysis  will  have  been  taken  away.  A  single 


594  THE    LOWER    EXTREMITY  [CHAP. 

nucleus  appears  in  this  epiphysis  shortly  before 
birth,  and  joins  the  shaft  about  the  age  of 
20-21.  The  limits  to  the  tibial  epiphysis  are  repre- 
sented behind  and  at  the  sides  by  a  horizontal  line 
that  just  marks  off  the  tuberosities.  It  includes, 
therefore,  the  depression  for  the  insertion  of  the 
semimembranosus,  and  also  the  facet  for  the  fibula. 
In  front  the  epiphyseal  line  slopes  downwards  on 
either  side  to  a  point  on  the  upper  end  of  the  shin, 
so  as  to  enclose  the  whole  of  the  tubercle  of  the 
tibia  (Fig.  134).  The  centre  joins  the  main  bone  at 
the  twenty-first  or  twenty-second  year.  The  popli- 
teal artery  runs  some  risk  of  being  wounded  in 
excision  of;  the  joint.  The  vessel  is  separated  by 
some  little^  distance  from  the  popliteal  surface  of 
the  femur  (Fig.  133),  but  is  in  very  close  relation 
to  the  tibia,  the  posterior  ligament  alone  inter- 
vening at  the  upper  level  of  the  bone.  It  thus 
happens  that  the  risk  of  wounding  the  artery  is 
greater  when  the  tibia  is  sawn  than  when  the 
lower  part  of  the  femur  is  being  removed. 

Excision  of  the  knee  is,  to  a  large  extent, 
replaced  by  arthrectomy.  Indeed,  excision  of 
this  joint  carried  out  in  the  complete  manner 
just  described  must  be  classed  as  quite  a  rare 
operation. 

Rest  for  the  knee= joint.— In  the  early  stages 
of  injuries  and  diseases  of  the  knee-joint  the 
surgeon's  first  aim  is  to  secure  rest  for  the  joint; 
his  second  and  subsequent  aim  is  to  restore 
function.  Now,  to  secure  rest  of  the  knee-joint 
it  is  necessary  to  rest  also  the  hip-  and  ankle- 
joints,  because  many  of  the  muscles  which  act 
on  the  knee  act  also  on  the  hip  or  ankle.  It  is 
manifest  that  such  double-joint  muscles  cannot 
be  thrown  out  of  action  until  all  the  joints  on 
which  they  act  are  immobilized.  So  soon  as  the 
acute  stage  is  over,  it  is  necessary  gradually  to 
restore  the  functions  of  the  rested  muscles;  that 
can  be  done  by  passive  and  active  movements, 
which  must  include  all  the  joints  of  the  lower 
limb. 


xxiv]  AMPUTATION  595 

Amputation  through  the  knee-joint. — To  il- 
lustrate the  anatomy  of  the  part  an  amputa- 
tion by  a  single  anterior  flap  may  be  selected. 
The  parts  involved  are  shown  in  Fig.  133. 
In  fashioning  the  anterior  flap  (composed  only 
of  integument),  and  in  opening  the  joint,  the 
patellar  plexus  of  nerves,  the  superficial  branches 
of  the  plexus  of  arteries,  the  ligamentum  pa- 
tellae, and  the  anterior  part  of  the  capsule  will 
be  cut.  Nearer  the  condyles  of  the  femur  the 
anastpmotic  and  the  two  superior  articular 
arteries  will  be  divided.  The  long  saphenous  vein 
and  nerve  will  be  divided  at  the  inner  angle  of 
the  flap.  On  the  cut  surface  made  by  the  posterior 
incision  will  be  found  divided  the  sartorius, 
gracilis,  and  semitendinosus,  the  semimembran- 
osus,  both  heads  of  the  gastrocnemius,  the  popli- 
teus,  plantaris,  and  biceps.  The  popliteal  vessels, 
the  sural  arteries,  the  snort  saphenous  vein,  the 
internal  and  external  popliteal  nerves  (tibial  and 
common  peroneal),  the  external  saphenous  and  the 
small  sciatic  nerves  will  also  be  found  divided 
in  the  same  incision. 

The  most  convenient  amputation  at  the  knee- 
joint  is  by  equal  lateral  flaps  (Stephen  Smith's 
operation).  This  operation  has  been  attended  by 
excellent  results,  and  in  actual  practice  the 
method  of  amputation  by  a  single  anterior  flap 
is  but  very  rarely  employed. 


CHAPTER    XXV 
THE    LEG 

Surface  anatomy.— The  anterior  border  of  the 
tibia  can  be  felt  in  its  entire  length,  forming, 
as  it  does,  the  prominence  of  the  shin.  It  should 
be  remembered  that  this  border  presents  a  some- 
what flexuous  course,  being  curved  outwards  above 
and  inwards  below.  The  broad  internal  surface 
of  the  bone  is  subcutaneous,  and  the  internal 
border  can  be  followed  from  the  tuberosity 
(medial  tibial  condyle)  to  the  malleolus.  The 
head  of  the  fibula  can  be  distinctly  made  out, 
but  the  upper  half  of  the  shaft  of  the  bone  is 
lost  beneath  the  mass  of  muscle  on  the  outer 
side  of  the  limb.  The  lower  half  of  the  fibular 
shaft  can  be  felt,  and  the  bone  just  above  the 
malleolus  becomes  subcutaneous  in  the  interval 
between  the  peroneus  tertius  and  the  two  other 
peroneal  tendons.  The  fibula  is  situated  so  far 
behind  the  line  of  the  tibia  that  a  knife  thrust 
transversely  through  the  leg  from  the  inner  side 
behind  the  tibia  will  appear  in  front  of  the  fibula 
on  the  outer  side  (Fig.  136).  Between  the  tibia  and 
fibula  the  outline  of  the  tibialis  anticus  muscle 
can  be  well  defined  when  it  is  in  action.  To  its 
outer  side  is  the  less  conspicuous  and  narrower 
eminence  formed  by  the  extensor  communis  digi- 
torum.  In  well-developed  limbs  the  groove  that 
separates  these  two  muscles  is  very  distinct,  and 
forms  the  best  guide  to  the  anterior  tibial-  artery. 
In  the  lower  third  of  the  leg  these  muscles  be- 
come tendinous,  and  between  them  the  extensor 
longus  hallucis  can  be  felt  as  it  cornea  to  the 
surface.  The  long  and  short  peroneal  muscles 
596 


SURFACE   ANATOMY   OF  LEG  597 

can  be  defined,  and  their  tendons  followed  behind 
the  malleolus.  When  in  active  contraction  the 
interval  between  the  two  muscles  is  often  well 
marked.  The  gastrocnemius  muscle  and  the  more 
superficial  parts  of  the  soleus  are  brought  well 
into  view  when  the  body  is  raised  upon  the  toes. 
The  two  heads  of  the  former  muscle  are  then  quite 
conspicuous,  and  it  can  be  seen  that  the  inner  head 
is  the  larger  and  descends  lower  in  the  leg. 

The  popliteal  artery  bifurcates  on  a  level  with 
the  lower  part  of  the  tubercle  of  the  tibia  (Fig.  128, 
p.  570).  The  course  of  the  posterior  tibial  vessel  is 
represented  by  a  line  drawn  from  a  point  midway 
between  the  inner  and  outer  borders  of  the  limb 
at  the  lower  part  of  the  ham  to  a  spot  midway 
between  the  inner  malleolus  and  the  prominence 
of  the  heel.  The  artery  becomes  superficial  in  the 
lower  fourth  of  the  leg,  where  it  maybe  felt  pulsat- 
ing between  the  tendo  Achillis  (calcaneus)  and  the 
tibia.  The  peroneal  artery  arises  about  3  inches 
below  the  knee,  follows  the  posterior  surface  of 
the  fibula,  and  ends  behind  the  outer  malleolus. 
The  position  of  the  anterior  tibial  artery  may  be 
indicated  by  a  line  drawn  from  a  point  midway 
between  the  outer  tuberosity  of  the  tibia  and  the 
head  of  the  fibula  to  the  centre  of  the  front  of  the 
ankle-joint.  Both  the  saphenpus  veins  can  often 
be  made  out  in  the  leg.  The  inner  or  larger  yein 
passes  in  front  of  the  malleolus  and  ascends  just 
behin d  the  internal  border  of  the  tibia.  With  it  runs 
the  long  saphenous  nerve.  The  short  saphenpus 
vein  lies  behind  the  outer  malleolus,  and,  passing 
up  the  middle  of  the  calf,  ends  at  the  ham.  It  is 
accompanied  by  the  external  saphenous  nerve. 

The  skin  is  somewhat  more  adherent  to  the 
deeper  parts  in  the,  leg  than  it  is  in  the  thigh. 
Tho  difference  in  the  degree  of  this  adhesion  is 
obvious  when  skin-flaps  are  dissected  up  from  the 
two  parts  in  cases  of  amputation.  Over  the  in- 
ternal surface  of  the  tibia  and  the  greater  part 
of  the  shin  the  integument  lies  directly^  upon  the 
periosteum  and  bone,  nothing  intervening  save  a 


598  THE    LOWER    EXTREMITY  [CHAP. 

scanty  amount  of  subcutaneous  fascia.  Thus  blows 
and  kicks  over  these  parts  of  the  leg  are  apt  to  be 
associated  not  only  with  much  pain  but  also  with 
much  bruising  or  tearing  of  the  integument.  A 
"  graze  on  the  shin  "  is  one  of  the  commonest  of 
lesions,  and  is  produced  by  a  degree  of  violence 
that  upon  a  well-covered  part  would  have  little 
or  no  effect.  It  will  be  understood  that  ulcers  over 
these  feebly  protected  parts  may,  if  they  spread 
in  depth,  readily  expose  the  bone  and  lead  to  some 
disease  of  its  substance,  or  at  least  to  some  inflam- 
mation of  its  periosteum.  Scars  left  by  deep 
ulcers  or  burns  are  also  often  found  to  be  quite 
adherent  to  the  bone. 

The  aponeiirosis  of  the  leg  invests  it  like  a 
tightly  drawn  buskin,  being  lacking  only  over  the 
subcutaneous  surface  of  the  bones.  (Fig.  136.)  It  is 
attached  to  the  head  and  the  anterior  and  inner 
borders  of  the  tibia,  the  head  of  the  fibula,  and 
the  two  malleoli.  It  is  continuous  above  with  the 
fascia  lata,  and  below  with  the  fascia  of  the  foot  and 
the  annular  ligaments.  It  is  thicker  in  front  than 
behind,  and  is  especially  thick  at  the  upper  part 
of  the  leg  just  below  the  knee.  Here  the  fascia 
offers  great  resistance  to  the  growth  of  tumours 
springing  from  the  head  of  the  tibia.  From  the 
deep  surface  of  the  aponeurosis  two  septa  pass 
inwards  to  be  attached  to  the  anterior  and  ex- 
ternal borders  of  the  fibula.  They  serve  to  isolate 
the  two  larger  peroneal  muscles  from  the  other 
muscles  of  the  limb,  and  form  a  closed  space  which 
might  become  a  definite  and  well-localized  cavity 
for  pus.  Beneath  the  gastrocnemius  and  soleus 
a  layer  of  fascia  extends  between  the  two  bones 
and  covers  in  the  deep  layer  of  muscles.  It  is 
thin  above  but  denser  below,  and  would  have 
some  influence  in  directing  the  progress  of  a  deep 
abscess.  In  paralytic  conditions  of  the  limb  tho 
fascial  expansions  and  sheaths  undergo  contrac- 
ture,  and  offer  resistance  when  the  surgeon  seeks 
to  restore  the  limb  to  its  normal  form  (Colin 
Mackenzie). 


xxv]  MUSCLES   OF  THE  LEG  599 

In  the  upper  third  of  the  leg  there  is  a  septum 
between  the  tibialis  anticus  and  extensor  com- 
munis  digitorum,  which  must  be  found  in  the 
operation  for  ligaturing  the  upper  part  of  the 
anterior  tibial  artery. 

In  the  substance  of  the  soleus  muscle  there  is 
a  tendinous  expansion  connected  with  the  inner 
border  of  the  tibia.  In  cutting  through  the  soleus 
to  apply  a  ligature  to  the  posterior  tibial  artery, 
it  is  possible  that  this  intersection  may  be  mis- 
taken for  the  aponeurosis  on  the  deep  surface 
of  the  muscle. 

Several  cases  are  reported  of  rupture  of  some 
part  of  the  gastrocnemius  muscle  during  violent 
exertion.  The  tendo  Achillis  has  been  ruptured 
in  like  circumstances.  This  accident  befell  the 
celebrated  John  Hunter  when  dancing.  It  ^  is 
said  that  the  plantaris  tendon  is  also  not  in- 
frequently torn  across,  producing  a  sudden  sharp 
pain  in  the  calf  during  exertion,  to  which  the 
French  give  the  name  "coup  de  /ouet." 

Vessels. — The  large  arteries  of  the  leg,  being 
all  in  close  proximity  to  the  bones,  are  apt  to 
be  injured  by  sharp  fragments  in  fractures  of 
the  limb.  This  especially  applies  to  the  peroneal 
artery,  which  runs  along  the  fibula  in  a  fibrous 
canal,  and  is  in  considerable  risk  of  being 
wounded  in  fractures  about  the  middle  of  that 
bone.  It  is  at  the  point  of  bifurcation  of  the 
popliteal  artery  that  emboli  are  peculiarly  apt  to 
lodge.  They  plug  the  vessel  and  practically  block 
the  three  main  arteries  of  the  leg.  Gangrene, 
therefore,  not  infrequently  follows  the  occurrence. 
It  is  a  remarkable  fact  that  gangrene  is  less 
likely  to  occur  when  the  vein  as  well  as  the 
artery  is  ligatured  (Makins). 

Varicose  veins  are  more  commonly  met  with 
in  the  leg  than  in  any  other  part  of  the  body, 
save,  perhaps,  in  the  hsemorrhoidal  and  spermatic 
veins.  This  depends  upon  the  great  length  of  the 
veins  of  the  lower  limb,  the  large  columns  of 
blood  their  valves  have  to  support,  their  vertical 


COO  THE    LOWER    EXTREMITY  [CHAP. 

position,  the  liability  of  the  great  trunks  (iliac), 
into  which  they  ultimately  enter,  to  be  compressed, 
and  upon  the  fact  that  the  superficial  veins,  being 
outside  the  fascia,  lose  that  assistance  to  the 
circulation  derived  from  muscular  contraction. 
From  a  physical  point  of  view  the  vascular  system 
must  be  regarded  as  a  vertical  column  of  fluid. 
The  lower  the  level  the  greater  is  the  pressure 
on  the  containing  walls.  The  saphenous  veins 
are  thin-walled,  distensible  tubes  situated  outside 
the  rigid-walled  cylinder  formed  by  the  deep 
fascia  of  the  leg  and  thigh,  low  in  the  body, 
where  the  pressure  from  gravity  is  greatest  (Hill). 
The  use  of  garters  especially  affects  the  long 
saphenous  vein,  which  lies  close  to  the  bone  at 
the  spot  about  which  these  contracting 
bands  are  usually  applied.  Between 
the  two  layers  of  the  muscles  of  the 
calf  Verneuil  describes  a  venous  plexus, 
which  he  believes  to  be  more  often  the 
seat  of  varices  than  are  the  vessels  of 
the  surface.  A  varicose  condition  of 
these  deeply  placed  veins  may  explain 
the  "aching  legs"  complained  of  by 
those  who  stand  a  great  deal.  The 
Fig.  135.  intramuscular  veins  are  very  large. 
Callender  showed  that  six  chief  veins 
which  pass  from^the  soleus  muscle  .to  enter  into 
the  posterior  tibial  and  peroneal  trunks  have  a 
united  diameter  of  not  less  than  1  inch.  Varix 
would  appear  to  commence  most  often  at  points 
where  the  deep  veins  join  the  superficial  vessels. 
There  is  good  reason  for  this,  for  at  these  points 
three  forces  meet,  the  general  directions  of  which 
are  shown  in  the  annexed  diagram  (Fig.  135). 
There  is  the  weight  of  the  superincumbent  column 
of  blood  (a)  acting  from  above,  the  resistance 
offered  by  the  next  valve  below  the  point  of  entry 
of  the  deep  vein  acting  from  below  (ft),  and  the 
force  with  which  the  blood  is  driven  by  the  con- 
tracting muscles  out  of  the  deep  vein  into  the 
superficial  trunk  acting  at  an  angle  to  both  these 


xxv]         REFERRED  PAIN   IN  THE  LEG          601 

lines  of  force  (c).  Unfortunately  for  the  subjects 
of  varices,  the  two  principal  veins  (the  saphenous) 
are  accompanied  by  sensory  nerves,  and  there  is 
no  doubt  that  much  of  the  pain  incident  to  vari- 
cose veins  in  the  leg  depends  upon  pressure  on 
these  nerves. 

With  reference  to  pain  in  tlie  leg,  it  must 
be  remembered  that  the  nerves  that  bring  sensa- 
tion to  the  part  arise  at  a  considerable  distance 
from  their  points  of  termination,  and  that  the 
causes  of  pain  in  the  limb  may  be  situated  far 
away^  from  the  seat  of  trouble.  Thus,  Sir  B. 
Brodie  mentions  the  case  of  a  gentleman  who  suf- 
fered from  severe  pain  in  the  left  leg,  from  the 
foot  to  the  knee,  in  the  course  of  the  peroneal 
I  nerve.  No  cause  could  be  found  for  it.  After 
the  patient's  death,  however,  a  large  tumour  was 
found  attached  to  the  lumbar  spine,  which  had 
evidently  compressed  the  left  great  sciatic  nerve. 
It  is  more  difficult  to  offer  an  explanation,  based 
on  anatomical  grounds,  for  cases  such  as  those 
reported  by  Sir  William  Bennett,  where  the  re- 
moval of  a  corn  from  the  sole  of  the  foot  in  one 
instance,  and  a  tumour  from  the  leg  in  another, 
was  followed  by  the  disappearance  of  a  pain 
which  had  been  felt  in  the  groin. 

There  would  appear  to  be  little  connexion 
between  disease  in  the  rectum  and  a  pain  in  the 
leg,  yet  in  one  case  at  least  that  connexion  was 
marked.  "Only  recently,"  writes  Hilton,  "I  saw 
a  gentleman  from  South  Wales,  who  was  the  sub- 
ject of  stricture  of  the  rectum  from  malignant 
disease.  He  suffered  pain  in  the  knee-joint  and  in 
the  back  part  of  the  leg.  This  led  me  to  suspect 
—what  really  turned  out,  upon  careful  examina- 
tion, to  be  the  case — that  a  large  mass  of  cancer 
was  involving  the  nerves  on  the  anterior  part  of 
the  sacrum,  and  also,  no  doubt,  the  obturator 
nerve."  Dr.  Ralfe  mentions  cases  of  renal  calculus 
attended  by  severe  pain  in  the  side  of  the  foot. 
I  (F.  T.)  have  met  with  many  such  instances,  the 
pain  being  most  commonly  in  the  heel. 


602  THE    LOWER    EXTREMITY  [CHAP. 

Fractures  of  the  leg.— The  tibia  and  fibula 
are  more  often  broken  together  than  singly,  and 
when  either  is  broken  alone  it  is  more  often  the 
fibula  than  the  larger  bone. 

1.  The  tibia  and  fibula. — As  regards  the  re- 
sistance it  offers  to  violence  the  fibula  presents 
about  the  same  degree  of  strength  in  all  its  parts, 
save  at  the  malleolus  and  at  its  upper  extremity. 
Its  great  length  and  the  manner  of  its  attachment 
to  the  tibia  (its  two  ends  being  fixed  and  its  main 
part  being  unsupported)  render  it  a  slender  bone, 
and  but  for  the  efficient  protection  it  derives  from 
the  thick  pad  of  muscles  that  surrounds  it,  it 
would  no  doubt  be  very  frequently  broken.  This 
is  all  the  more  likely  to  be  the  case,  since  the 
bone  is  placed  upon  the  more  exposed  aspect  of 
the  limb. 

The  shaft  of  the  tibia  presents  various  degrees 
of  strength,  according  as  we  regard  its  upper, 
middle,  or  lower  third.  According  to  Dr.  Leriche, 
the  average  transverse  diameter  of  the  adult 
tibia  just  below  the  tuberosities  is  a  little  over 
If  inches.  The  transverse  diameter  at  the  base  of 
the  malleolus  is  a  little  less  than  1|  inches,  and 
that  of  the  narrowest  part  of  the  bone  is  a  little 
more  m  than  1  inch.  This  narrow  part  is  at  the 
junction  of  the  lower  with  the  middle  third  of  the 
shaft,  and  is  the  weakest  point  in  the  bone.  Thus 
it  happens  that  the  most  common  spot  for  a  frac- 
ture of  the  tibia  is  at  the  junction  of  the  middle 
with  the  lower  third  of  the  shaft.  It  is  here  that 
the  bone  yields  when  broken  by  indirect  violence, 
while  the  lesions  depending  upon  direct  violence 
may  be  at  any  part  of  the  shaft.  Owing  to  the 
thin  covering  of  soft  parts,  and  the  slight  barrier 
interposed  between  the  fracturing  force  and  the 
bone,  it  comes  to  pass  that  fractures  of  the  leg  are 
more  often  compound  and  comminuted  than  are 
those  of  any  other  bones  of  the  extremities.  If  the 
fracture  be  oblique,  as  is  commonly  the  case  when 
the  violence  is  indirectly  applied,  the  line  of 
breakage  usually  extends  from  behind,  down- 


xxv]  FRACTURES   OF  THE   LEG  603 

wards,  forwards,  and  a  little  inwards.  The  lower 
fragment,  with  the  foot,  is  drawn  up  behind  the 
rest  of  the  bone  by  the  muscles  of  the  calf,  and^  is 
usually  displaced  also  outwards  by  the  obliquity 
of  the  fracture  line.  Often  the  lower  fragment  is 
slightly  rotated  outwards  by  the  rolling  over  of 
the  foot,  a  rotation  produced  by  the  simple  weight 
of  the  limb.  If  the  fracture  be  transverse  there 
may  be  little  or  no  displacement.  The  fibula  is 
usually  broken  at  a  higher  level  than  the  tibia, 
and  its  lower  fragment  follows,  of  course,  with 
absolute  precision  the  corresponding  fragment  of 
the  larger  bone.  A  remarkable  spiral  fracture 
(fracture  helico'ide),  involving  the  lower  third  of 
the  tibia,  has  been  described  by  French  surgeons. 
It  is  associated  with  a  more  or  less  vertical  fissure 
that  involves  the  ankle-joint,  and  with  a  fracture 
of  the  fibula  high  up..  MM.  Leriche  and  Tillaux 
have  shown  that  this  injury  is  due  to  torsion, 
especially  to  some  twisting  of  the  leg  while  the 
foot  is  fixed. 

2.  The  fibula  alone. —  Fractures  of  this  bone^in 
its  lower  fourth  are  usually  due  to  indirect  vio- 
lence,  and  will  be  dealt  with  in  connexion  with 
the  ankle-joint.     When  it  is  broken  in  any  other 
part  the  fracturing  force  is  usually  directly  ap- 
plied, the  lesion  transverse,  and  the  displacement 
insignificant  or  scarcely  obvious.     The  tibia  acts 
as  an  efficient  splint. 

3.  The  tibia   alone.  —  The    malleolus    may    be 
broken  by  a  blow,,  or  the  lower  epiphysis  sepa- 
rated.   The  latter  comprises  the  whole  of  the  inner 
malleolus  and  the  facet  with  which  the  fibula  arti- 
culates.    It  joins  the  shaft  during  the  eighteenth 
or  nineteenth  year.     Fractures  of  the  tibia  alone 
are  nearly  always  due  to  direct  violence;  whilst 
most  common  in  the  lower  third  of  the  bone,  they 
become    more    rare    as    the    knee    is    approached. 
When  transverse  there  may  be  no  visible  displace- 
ment, the  fibula  acting  as  a  splint.  Thus,  Sir  Henry 
Morris  mentions  the  case  of  a  woman  who  walked 
into    and   out    of    a   hospital    with    a   transverse 


604 


THE    LOWER    EXTREMITY 


[CHAP. 


fracture  of  the  tibia  that  was  not  detected  on 
examination,  and  was  not,  indeed,  discovered  until 
two  days  after  the  accident.  When  the  fracture 
is  just  above  the  ankle  the  lower  fragment  may 
be  moved  in  whatever  direction  the  foot  is  forced, 
such  displacement  being  resisted  and  limited  by 
the  inferior  tibio-fibular  ligaments. 

In  rickets  the  tibia  is,  of  all  the  bones  of  the 
extremities,  the  one  that  most  frequently  becomes 


.  ANTICUS 


PERON.    LONG. 


ANT.  TIB.  ART. 


POST.  TIB.   N. 


PERON.  ART 
FLEX.   LONG.   HALL. 


GASTROCNEM. 


Fig.   136. — Section  across  the  leg  at  the  junction  of  the 
upper  and  middle  thirds.      (After  Braune.) 

bent.  It  yields  at  its  weakest  part  (the  junction 
of  the  middle  and  lower  third),  and  there  the 
bone  will  be  found  to  have  developed  a  curve 
forwards  and  a  little  outwards. 

The  fibula  is  occasionally  absent,  a  cir- 
cumstance usually  associated  with  a  deformity 
of  the  foot  and  absence  of  two  or  more  of  the 
outer  toes.  The  subcutaneous  position  of  the  tibia 
makes  it  the  favourite  site  from  which  to  obtain 
bone-grafts. 


xxv] 


AMPUTATION   OF   THE   LEG 


605 


Amputation  at  the  junction  of  the  upper 
with  the  middle  third  by  unequal  antero-posterior 
flaps  may  be  taken  as  an  example  of  amputations 
of  the  leg  (see  Fig.  136).  In  the  anterior  flap 
the  following  structures  would  be  cut:  Skin, 
cutaneous  nerves,  fascia,  tibialis  anticus,  extensor 
communis  digitorum  and  a  little  of  the  extensor 
proprius  hallucis,  the  peroneus  longus  and  a 


Fig.    137.  —Transverse   section   through   the    lower    third 
of  the  leg.      (Braune.} 

a,  Tibialis  anticus  ;  5,  extensor  longus  hallucis  ;  c,  extensor  communis 
digitorum  ;  d,  peroneus  brevis  ;  e,  peroneus  longus  ;  /,  tibialis 
posticus ;  <7,  flexor  longus  digitorum  ;  h,  flexor  longus  hallucis  ; 
i,  gastrocnemius  and  soleus  ;  j,  short  saphenous  nerve  and  vein  ; 
k,  anterior  tibial  vessels  and  nerve;  Z,  peroneal  vessels;  m,  pos- 
terior tibial  vessels  and  nerve  ;  n,  musculo-cutaneous  nerve. 

small  part  of  the  upper  extremity  of  the  peroneus 
brevis,  the  anterior  tibial  vessels  and  nerve,  and 
the  musculo-cutaneous  nerve.  In  the  posterior 
flap  the  following  would  be  the  parts  divided : 
Skin,  external  and  internal  saphenous  veins  and 
nerves,  fascia,  gastrocnemius,  plantaris,  soleus, 
tibialis  posticus,  flexor  longus  digitorum,  a  little 
of  the  upper  end  of  the  flexor  longus  hallucis, 


606  THE    LOWER    EXTREMITY 

the  posterior  tibial  vessels  and  nerve,  and  the 
peroneal  vessels. 

In  Fig.  137  is  shown  a  transverse  section  of  the 
leg  at  the  lower  third,  from  which  can  be  gathered 
an  idea  of  the  number  and  position  of  the  parts 
cut  in  amputations  through  that  part. 

An  excellent  method  of  amputation  at  the 
upper  part  of  the  leg  is  by  a  single  external  flap 
containing  the  anterior  tibial  artery  in  its  entire 
length. 


CHAPTER   XXVI 
THE   ANKLE   AND   THE   FOOT 

Surface  anatomy.  Bony  points.— The  outlines 
of  the  two  malleoli  can  be  very  distinctly  defined. 
The  external  is  somewhat  the  less  prominent, 
descends  lower,  and  lies  farther  back  than  the 
internal  process.  The  tip  of  the  outer  malleolus 
is  about  ^  an  inch  behind  and  below  the  tip  of 
the  corresponding  bony  prominence.  The  antero- 

Eosterior  diameter,  however,  of  the  internal  mal- 
jolus  is  such  that  its  posterior  border  is  on  a 
level  with  that  of  the  outer  process  behind. 

On  the  dorsum  of  the  foot  the  individual  tarsal 
,  bones  are  not  to  be   distinguished,   although  the 
1  astragalus  forms  a  distinct  projection  upon  that 
surface  when  the  foot  is  inverted. 

On   the  inner  side  of  the  foot  the  tuberosity 

i  of   the    os    calcis    (caleaneus)    may    be    felt   most 

posteriorly.      In    front  of   it,    and   about   1   inch 

I  vertically  below  the  inner  malleolus,  is  the  pro- 

j  jection  of  the  sustentaculum  tali.    About  1|  inches 

|  in   front  of  the  malleolus   the  tuberosity  of   the 

j  scaphoid  (navicular)  can  be  distinctly  made  out 

(Fig.    140,    p.    625).      In   the   interval   between   it 

and     the     last-named     process     lie    the     inferior 

calcaneo-scaphoid    ligament,    and    the    tendon    of 

the  tibialis  posticus.     Farther  towards  the  front 

of  the  foot  can  be  felt  the  ridge  formed  by  the 

base  of  the  first  metatarsal  bone,  and  between  it 

and  the  scaphoid  tubercle  (process)  lies  the  inner 

cuneiform   bone.      Lastly,    the   shaft   of   the   first 

•  metatarsal  bone,  its  expanded  head,  and  the  sesa- 

moid  bones  that  lie  on  the  plantar  aspect  of  the 

metatarsal  phalangeal  joint  can  be  more  or  less 

607 


608  THE    LOWER    EXTREMITY  [CHAP. 

distinctly  defined.  On  the  outer  side  of  the  foot  the 
external  surface  of  the  os  calcis  is  subcutaneous  in 
nearly  the  whole  of  its  extent.  Less  than  1  inch 
below  and  in  front  of  the  malleolus  is  the  peroneal 
tubercle,  with  the  short  peroneal  tendon  above  it 
and  the  long  one  below  it.  Some  2^  inches  from 
the  outer  malleolus  the  tuberosity  of  the  fifth 
metatarsal  bone  is  very  evident,  and  extending 
for  an  inch  or  so  behind  it  lies  the  cuboid  bone. 

joint -lines. — The  ankle-joint  lies  about  on  a 
level  with  a  point  i  an  inch  above  the  tip  of  the 
inner  malleolus.  Immediately  behind  the  tubercle 
of  the  scaphoid  is  the  astragalo-scaphoid  articula- 
tion, and  a  line  drawn  transversely  across  the 
dorsum  of  the  foot,  just  behind  the  process,  very 
fairly  corresponds  to  the  mid-tarsal  joint  (the 
joint  compounded  of  the  astragalo-scaphoid  and 
calcaneo-cuboid  articulations). 

If  the  latter  articulation  be  approached  from 
the  outer  side  it  will  lie  opposite  a  point  midway 
between  the  outer  malleolus  and  the  tuberosity  of 
the  fifth  metatarsal  bone, 

The  lines  of  the  articulations  between  the  first 
and  fifth  metatarsal  bones  and  the  inner  cunei- 
form and  the  cuboid  respectively  are  easily  indi- 
cated, being  placed  just  behind  the  bases  of  the 
former  bones.  The  metatarso-phalangeal  articula- 
tions are  situated  about  1  inch  behind  the  webs  of 
the  corresponding  toes.  The  proximal  phalanx 
and  part  of  the  middle  are  buried  in  the  web. 

Tendons. — The  tendo  Achillis  (calcaneus)  stands 
out  very  conspicuously  at  the  back  of  the  ankle, 
and  between  it  and  the  malleoli  are  two  hollows 
which  are  evident  in  even  obese  individuals.  Over 
the  front  of  the  ankle  the  tendons  of  the  extensor 
muscles  are  readily  to  be  distinguished,  especially 
when  the  joint  is  flexed.  From  within  outwards 
they  are  :  the  tendons  of  the  tibialis  anticus,  ex- 
tensor longus  hallucis,  extensor  longus  digitorum, 
and  peroneus  tertius.  Beneath  the  tendons  of  the 
extensor  of  the  toes,  and  on  the  outer  part  of 
the  dorsum  of  the  foot,  the  prominent  fleshy  mass 


xxvi]       VESSELS   OF  ANKLE   AND   FOOT          609 

formed  by  the  extensor  brevis  digitorum  can  be 
felt  and,  when  in  action,  seen.  Above  and  behind 
the  inner  malleolus  the  tendons  of  the  tibialis 
posticus  and  flexor  longus  digitorum  can  be  dis- 
cerned, the  former  lying  nearer  to  the  bone. 
Nearer  to  the  middle  line  runs  the  flexor  longus 
hallucis.  Behind  the  outer  malleolus  the  long  and 
short  peroneal  tendons  can  be  felt,  lying  close  to 
the  edge  9f  the  fibula,  the  tendon  of  the  smaller 
muscle  being  the  closer  to  it. 

In  the  middle  of  the  sole  of  the  foot  the  resist- 
ing plantar  fascia  (aponeurosis)  can  be  felt,  and 
some  of  its  processes  made  out  when  the  toes  are 
drawn  up  by  the  extensors.  The  fleshy  mass  on 
the  inner  margin  of  the  foot  is  formed  by  the 
abductor  and  flexor  brevis  hallucis;  that  on  the 
outer  side  by  the  abductor  and  flexor  brevis 
minimi  digiti. 

Vessels.— The  anterior  tibial  artery  and  (deep 
peroneal)  nerve  are  placed  opposite  the  ankle- 
joint,  between  the  tendons  of  the  extensor  pro- 
prius  hallucis  and  longus  digitorum.  The  dorsal 
artery  runs  from  the  middle  of  the  ankle  to  the 
interval  between  the  bases  of  the  first  and  second 
metatarsal  bones.  It  may  be  felt  ^  pulsating, 
against  the  bones  along  the  outer  side  of  the 
extensor  proprius  hallucis  tendon,  which  is  the 
readiest  guide  to  it.  The  plantar  arteries  start 
from  a  point  midway  between  the  tip  of  the 
malleolus  internus  and  the  centre  of  the  con- 
vexity of  the  heel.  The  internal  vessel  follows- 
a  line  drawn  from  this  point  "to  the  middle  of 
the.  under  surface  of  the  great  toe.  The  external 
vessel  crosses  the  sole  obliquely  to  within  a 
thumbVbreadth  of  the  base  of  the  fifth  meta- 
tarsal bone.  From  thence  it  turns  more  trans^ 
versely  across  the  foot,  running  inwards  over  the 
bases  of  the  metatarsal  bones  to  inosculate  with 
the  dorsalis  pedis  artery  at  the  back  of  the  first 
interosseous  space.  On  the  dorsum  of  the  foot  the 
subcutaneous  veins  may  be  seen  forming  an  arch, 
convex  towards  the  toes,  and  from  the  ends  of- the 
u 


610  THE    LOWER    EXTREMITY  [CHAP, 

arch  vessels  may  be  followed  into  the  internal  and 
external  saphenous  veins. 

The  skin  about  the  ankle  and  over  the  dor- 
sum  of  the  foot  is  thin  and  but  loosely  attached 
to  the  subjacent  parts.  It  becomes  readily  ex- 
coriated, as  is  frequently  the  case  where  splints 
or  instruments  have  been  improperly  applied. 
Since  the  skin  over  the  malleoli  lies  directly 
upon  the  bone,  while  that  covering  the  dorsuni 
of  the  foot  is  but  slightly  separated  from  the 
bones  of  the  tarsus,  it  follows  that  the  integu- 
ments in  this  region  are  readily  contused,  and 
may  suffer  gangrene  from  an  amount  of  pressure 
that  would  cause  but  little  trouble  in  other  parts. 
Over  the  sole  the  integument  is  dense  and  thick  in 
all  those  parts  that  come  in  contact  with  the 
ground.  In  the  normal  foot,  the  heel,  the  outer 
margin  of  the  foot,  and  the  line  of  metatarso- 
phalangeal  joints  are  in  contact  with  the  ground 
when  the  sole  is  placed  flat  upon  it  (Fig.  142, 
p.  633). 

The  subcutaneous  tissue  about  the  ankle  and 
foot  varies  greatly  both  in  quantity  and  charac- 
ter. Over  the  front  of  the  ankle  and  dorsum  of 
the  foot  it  is  very  lax,  freedom  fat,  and  is  the 
first  part  to  be  infiltrated  in  general  dropsy  of 
the  body.  On  the  sole  the  subcutaneous  tissue  is 
dense,  firm,  and  studded  with  pellets  of  fat.  It 
is  f  of  an  inch  thick  over  the  heel. 

The  integuments  of  the  foot  are  well  supplied 
with  nerves,  being  furnished  with  branches  from 
no  less  than  six  nerve  trunks — the  musculo-cuta- 
neous  (superficial  peroneal),  the  anterior  tibial 
(deep  peroneal),  the  two  saphenous,  and  the  ex- 
ternal and  internal  plantar.  Many  Pacinian 
bodies  are  found  upon  these  cutaneous  branches, 
and  end-bulbs  are  met  with  in  the  skin  on  the 
sole.  The^integuments  of  the  foot  respond  acutely 
to  sensations  of  pain,  of  pressure,  of  tempera- 
ture, and  to  certain  <  unwonted  forms  of  tactile 
impression,  such  as  tickling.  Many  postural  re- 
flexes arise  from  the  skin  of  the  sole,  as  well 


xxvij      DORSAL  AND   PLANTAR   FASCIA         611 

as  from  the  joints  of  the  foot;  the  clinician  uses 
these  reflexes  to  test  the  state  of  the  lumbar  part 
of  the  spinal  cord.  Tactile  insensibility,  however, 
as  measured  by  the  sesthesiometer,  is  not  acute, 
the  dorsum  of  the  foot  showing,  in  regard  to  this 
matter,  no  more  sensitiveness  than  does  the  skin 
of  the  buttock. 

Over  the  "tread  of  the  foot,"  and  especially 
under  the  ball  of  the  great  toe,  the  peculiar 
affection  known  as  "perforating  ulcer"  is  most 
commonly  met  with.  This  ulcer  occurs  as  an 
occasional  symptom  in  certain  nerve  maladies, 
and  particularly  in  locomotor  ataxy. 

Fasciae    of     the    loot    and    tkc    tendons 
about    the    ankle.  —  The    dorsal    fasciae    occur 
in    two    layers,    a    superficial    one    that    is    con- 
tinued from  the  upper  anterior  annular  ligament 
(transverse   ligament  of   the   leg),    and   a  deeper 
placed   over    the   extensor    brevis    and    interossei 
muscles.      These   membranes    are    both    thin    and 
insignificant,    and   exercise   no   influence   from   a 
surgical    point   of   view.      The    plantar   fascia   is 
divided  into  three  parts,  a  central  or  main  por- 
i  tion  which  is  extremely  dense  and  powerful,  and 
j  an  inner  and  an  outer  expansion  which  are  thin 
i  and   surgically    insignificant.      The   outer    of   the 
j  two   lateral   portions   is,    however,    of   some   sub- 
1  stance,    and    forms    a    very   thick    band    between 
j  the  os  calcis  and  the  tuberosity  of  the  fifth  meta- 
i  tarsal  bone,  that  may  become  rigidly  contracted 
in  some  forms  of  talipes.     The  central  expansion 
i  accommodates   itself  to  the  abnormal   conditions 
of  the  foot:   if  the  arch  of  the  foot  collapses,  as 
in  fiat-foot,   it  becomes  stretched  and  elongated; 
if,  on  the  other  hand,  the  arch  becomes  bent,  as 
!  in  pes  cavus,  resulting  from  paralysis  of  extensors 
j  of   the   foot,    the   fascia  becomes   contracted    and 
'  taut. 

The  best  place  in^  which  to  divide  this  membrane 
is  at  a  spot  about  1  inch  in  front  of  its  attachment 
to  the  ps  calcis.  This  is  its  narrowest  part,  and 
the  knife  (which  should  be  introduced  from  the 


612  THE    LOWER    EXTREMITY  [CHAP. 

inner  side)  will  be  behind  the  external  plantar 
artery  which  runs  beneath  the  expansion. 

An  abscess  situated  beneath  the  membrane  will 
be  very  closely  bound  down,  and  will  advance  in 
any  direction  other  than  through  the  membrane 
itself.  Such  deep  collections  cause  intense  pain,  and 
often  much  destruction,  before  they  are  discharged. 
They  may  open  upon  the  dorsum,  or  may  extend 
up  along  the  tendons  to  the  region  of  the  ankle. 
There  are  certain  foramina  or  spaces  in  the  sub- 
stance of  this  layer  occupied  usually  by  fat; 
through  one  or  more  of  these  an  abscess  will,  in 
exceptional  cases,  extend,  and  then  spread  out  be- 
neath the  integuments.  Such  an  abscess  will  have, 
therefore,  two  cavities  united  by  a  small  hole,  and 
will  form  the  abces  en  bissac  or  en  bouton  de 
chemise  of  the  French.  The  plantar  fascia  divides 
into  slips  near  the  roots  of  the  toes,  and  forms  a 
series  of  arches,  beneath  which  pass  the  tendons, 
vessels,  and  nerves  bound  for  the  digits.  Two 
intermuscular  septa  connected  with  the  membrane 
separate  the  flexor  brevis  digitorum  from  the  ab- 
ductor hallucis  on  the  one  side  and  the  abductor 
minimi  digiti  on  the  other.  They  are,  however, 
membranes  of  too  feeble  a  structure  to  affect  much 
the  progress  of  a  deep  plantar  abscess. 

The  anterior  annular  ligament  is  divided  into 
two  parts — an  upper  band  (transverse  ligament) 
in  front  of  the  tibia  and  fibula,  and  a  lower  band 
(cruciate  ligament)  in  front  of  the  upper  limits 
of  the  tarsus  (Fig.  138).  Beneath  the  former 
there  is  only  one  synovial  sheath,  that  for  the 
tibialis  anticus;  beneath  the  latter  are  three 
sheaths — one  for  the  peroneus  tertius  and  ex- 
tensor communis,  one  for  the  extensor  proprius 
pollicis,  and  a  third  for  the  tibialis  anticus. 

There  is  often  a  large  irregular  bursa  between 
the  tendons  of  the  extensor  longus  digitorum  and 
the  projecting  head  of  the  astragalus.  This  bursa 
sometimes  communicates  with  the  joint  at  the 
head  of  the  astragalus. 

Beneath  the  internal  annular   ligament  (liga- 


xxvi] 


ANNULAR   LIGAMENTS 


613 


mentum  laciniatum)  are  three  synovial  sheaths 
for  the  tendons  of  the  tibialis  posticusr  flexor 
longus  digitorum,  and  flexor  longus  ha'llucis.  In- 
flammation involving  the  sheath  for  the  tibialis 


UPPER  ANT.  ANN.   LIG. 


LOWER  ANT.  ANN.   LIQ. 


PERON.  TERTIUS 


TIB.  ANTICUS 


.  LONG.   HALU 


EXT.  BREV.  HALL* 


Fig.  138. — Synovial    sheaths   on   the   extensor   surface   of 
foot  and  ankle.     (Lovell  and  Tanner.} 

posticus  may  spread  to  the  ankle-joint,  with 
which  the  tendon  is  in  close  relation.  Beneath 
the  outer  annular  ligament  (peroneal  retinacu- 
lum)  is  the  single  synovial  sheath  for  the  long 
and  short  peroneal  tendons. 


614  THE    LOWER    EXTREMITY  [CHAP. 

In  severe  sprains  of  the  ankle  not  only  are  the 
ligaments  about  the  joint  more  or  less  ruptured, 
but  the  various  synovial  sheaths  just  named  are 
apt  to  be  torn  and  filled  with  blood.  The  long- 
abiding  trouble  which  often  follows  severe  sprains 
depends  to  a  great  extent  upon  damage  to  these 
sheaths,  and  to  extravasations  of  blood,  and 
subsequently  of  inflammatory  material,  within 
them.  Tendons  become  fixed  within  their  sheaths 
by  the  formation  of  adhesions,  thus  tethering  the 
muscles  and  stiffening  the  joint.  Until  these 
adhesions  are  elongated  by  passive  and  active 
movements,  or  broken  down  and  absorbed,  there 
can  be  no  restoration  of  function.  The  tendon- 
sheaths  are  more  extensive  than  they  are  usually 
supposed  to  be;  those  at  the  inner  side  of  the 
ankle  commence  from  1  to  2  inches  above  the 
malleolus,  and  extend  into  the  sole  of  the  foot 
to  a  point  opposite  the  tuberosity  of  the  scaphoid. 
Those  at  the  outer  side  of  the  ankle  are  even 
more  extensive,  that  round  the  peroneus  longus 
extending  to  the  base  of  the  first  metatarsal, 
although  occasionally  the  plantar  and  malleolar 
parts  may  be  found  completely  separated  from 
each  other  at  the  outer  border  of  the  cuboid. 
From  the  length  of  the  sheaths  it  can  be  readily 
understood  that  the  adhesions  which  follow 
sprains  and  fractures  at  the  ankle  are  very  ex- 
tensive, and  need  constant  and  patient  treatment. 

There  are  few  fonrsse  of  any  magnitude  about 
the  foot,  save  one  between  the  tendo  Achillis  and 
os  calcis,  and  another  over  the  metatarso-phalan- 
geal  joint  of  the  great  toe.  The  first-named  bursa 
rises  about  \  an  inch  above  the  os  calcis,  and 
bulges  out  on  either  side  of  the  tendon.  When  in- 
flamed it  may  produce  symptoms  like  those  of 
ankle-joint^  disease,  and  when  suppurating  may 
lead  to  caries  of  the  os  calcis.  The  enlargement  of 
the  bursa  over  the  metatarso-phalangeal  joint  of 
the  great  toe  constitutes  a  bunion.  It  lies  in  the 
subcutaneous  tissue  between  the  internal  sesamoid 
and  the  skin,  and  comes  into  existence  with  the 


xxvi]  HALLUX   VALGUS  615 

production  of  the  common  condition  known  as 
hallux  valgus.  The  great  toe  becomes  abducted, 
bent  towards  the  middle  line  of  the  foot.  This 
condition,  like  genu  valgum  and  flat-foot,  is  the 
result  of  a  disordered  action  of  the  muscles  which 
regulate  the  position  of  the  proximal  phalanx 
of  the  great  toe.  When,  at  the  end  of  a  step, 
the  heel  is  raised,  the  proximal  phalanx  and 
its  sesamoids  form  a  socket  in  which  the  head 
of  the  metatarsal  bone  of  the  great  toe  rotates 
(Fig.  140,  p.  625).  During  this  act  the  proximal 
phalanx  is  balanced  by  two  muscles :  the  abductor 
prevents  its  rotation  outwards;  the  adductor, 
inwards.  The  chief  strain  falls  on  the  abductor, 
often  handicapped  and  confined  by  ill-fitting  or 
too  tightly  fitting  boots.  The  adductor  is  thus 
left  unbalanced,  and  it  draws  the  toe  gradually 
into  an  abducted  position.  The  cartilage  over 
the  inner  part  of  the  head  of  the  metatarsal  bone 
disappears,  and  a  communication  between  the 
bursa  and  joint  may  be  set  up.  The  result  of 
this  deformity  is  a  great  weakening  of  the  toe 
and  adjacent  part  of  the  foot,  a  lengthening  of 
the  internal  lateral  ligament  of  the  joint,  and 
a  displacement  outwards  of  the  tendon  of  the 
extensor  proprius  hallucis.  Bursse  are  often  de- 
veloped over  the  malleoli  in  tailors,  and  especi- 
ally over  the  external  process,  the  part  most 
pressed  upon  when  sitting  cross-legged.  In  club- 
foot,  bursse  are  found  over  any  points  that  are 
exposed  to  undue  pressure. 

The  tendons  about  the  ankle  are  not  infre- 
quently ruptured  by  violence.  Those  that  most 
often  are  so  injured  are  the  tendo  Achillis  and  the 
tendons  of  the  tibialis  posticus  and  the  long  and 
short  peroneal  muscles.  The  tendo  Achillis  usually 
breaks  at  a  point  about  li  inches  above  its  inser- 
tion, where  it  becomes  narrowed  and  its  fibres 
collected  into  a  very  definite  bundle. 

In  some  forms  of  f  violence  the  synovial  and 
fibrous  sheaths  that  bind  down  a  tendon  may  be 
raptured  and  the  tendons  thus  become  dislocated. 


616  THE    LOWER    EXTREMITY          [CHAP. 

This  has  happened  to  the  tibialis  posticus  and 
peroneal  muscles.  In  each  instance  the  dislo- 
cated structure  comes  forward  upon  or  in  front 
of  the  malleolus.  No  tendon  in  the  body  is  so 
frequently  displaced  as  is  that  of  the  peroneus 
longus. 

The  tendons  about  the  ankle  are  frequently 
divided  by  operation,  in  nearly  all  cases  the 
open  operation  being  preferred  to  a  subcutaneous 
tenotomy.  The  tendo  Achillis  is  usually  cut 
about  1  inch  above  its  insertion,  the  knife  being 
entered  from  the  inner  side  to  avoid  the  posterior 
tibial  vessels.  The  tibialis  posticus  tendon  is, 
as  a  rule,  divided  just  above  the  base  of  the 
inner  malleolus.  There  is,  however,  enough  room 
between  the  annular  ligament  and  the  scaphoid 
bone  to  cut  it  on  the  side  of  the  foot  (Fig. 
141,  p.  631).  The  anterior  tibial  tendon  may  be 
divided  readily  either  in  front  of  the  ankle  or  at 
its  insertion  into  the  internal  cuneiform  bone,  and 
one  or  both  peronei  just  above  the  external  mal- 
leolus. On  section  of  a  tendon  a  gap  is  felt, 
owing  to  retraction  by  the  muscle.  The  cut  ends 
are  still  united  by  the  fibrous  tissue  in  which 
they  lie,  and  from  which  they  derive  their  blood 
supply.  If  cut  within  a  sheath  the  synovial 
membrane  forms  a  loose  binding  between  the 
cut  ends.  A  fibrous  band  between  the  cut  ends 
is  ultimately  formed  from  the  effusion  which  fills 
the  gap.  The  new  band  is  firmly  adherent  to  the 
sheath  in  which  it  lies,  and  at  first  will  limit 
the  movements  of  the  tendon. 

Part  of  the  tendon  of  a  sound  muscle  may  be 
yoked  to  that  of  one  which  has  become  paralysed, 
thus  restoring  certain  movements  to  the  foot. 

Blood-vessels. — The  lines  of  the  various  arte- 
ries have  been  already  indicated  (p.  609).  Wounds 
of  the  plantar  arch  are  serious,  on  account  of  the 
depth  at  which  the  external  plantar  artery  lies, 
and  the  impossibility  of  reaching  the  vessel  with- 
out making  a  large  wound  in  the  sole  that  would 
open  up  important  districts  of  connective  tissue 


xxvr]          VESSELS   OF   PLANTAR   ARCH  617 

and  do  damage  to  tendons  and  nerves.  The  arch 
is  formed  by  the  junction  of  the  external  plantar 
artery  with  the  dorsal  artery  of  the  foot,  a  con- 
tinuation of  the  anterior  tibial  vessel.  In  cases, 
however,  of  bleeding  from  the  arch,  ligature  of 
both  the  posterior  and  anterior  tibial  vessels  at  or 
just  above  the  ankle  would  not  necessarily  arrest 
the  haemorrhage.  After  ligature  of  these  vessels 
blood  would  still  be  brought  indirectly  to  the  arch 
by  means  of  the  peroneal  artery.  By  its  anterior 
peroneal  branch  this  vessel  communicates  with  the 
external  malleolar  branch  of  the  anterior  tibial 
artery,  and  with  the  tarsal  branch  of  the  dorsalis 
pedis.  By  its  terminal  branch  it  communicates 
with  the  two  last-named  vessels,  and  also  with  the 
internal  calcaneal  branches  of  the  external  plan- 
tar artery. 

As  a  matter  of  practice,  however,  elevation 
of  the  limb,  together  with  pressure  upon  the 
wounded  point  and  compression  of  the  main 
artery,  is  sufficient  to  check  most  haemorrhages 
from  the  plantar  arch. 

The  dorsalis  pedis  artery,  from  its  superficial 
position  and  its  close  contact  with  the  bones  of  the 
foot,  is  frequently  divided  in  wounds  and  rup- 
tured in  severe  contusions.  The  posterior  tibial 
artery  at  the  ankle  is  well  protected  by  the  pro- 
jecting malleolus,  the  dense  annular  ligament,  and 
the  tendons  that  run  by  its  side. 

The  superficial  veins  of  the  foot,  like  those  of 
the  hand,  are  found  mainly  upon  the  dorsum  of 
the  member.  The  sole,  as  a  part  exposed  to  pres- 
sure, is  singularly  free  from  them.  About  the 
malleoli,  and  especially  about  the  inner  process, 
these  veins  form  a  considerable  plexus.  Hence  it  is 
that  appliances  which  fit  tightly  around  the  ankle 
are  apt  to  produce  oedema  and  pain  in  the  parts 
beyond. 

The  lymphatics  form  a  very  fine  and  elabo- 
rate plexus  in  the  coverings  of  the  sole,  from 
which  vessels  arise  that  reach  the  borders  and  dor- 
sum  of  the  foot,  and  principally  the  inner  border. 
u* 


618  THE    LOWER    EXTREMITY  [CHAP. 

The  main  lymph-vessels  of  the  part  are  found 
upon  the  dorsum,  about  the  radicles  of  the  two 
saphenous  veins.  Those  on  the  inner  side  of  the 
foot  are  by  far  the  more  numerous ;  they  follow 
pretty  generally  the  course  of  the  internal  saphen- 
ous vein,  and  end  in  the  inguinal  glands.  The 
external  vessels  pass  up  along  the  outer  ankle  and 
outer  side  of  the  leg.  The  bulk  of  them  pass 
obliquely  across  the  ham  to  join  the  inner  set 
above  the  knee ;  others  reach  the  inner  set  by  cross- 
ing the  front  of  the  tibia,  while  a  few  follow  the 
short  saphenous  vein  and  end  in  the  popliteal 
glands  (see  p.  577). 

The  ankle-joint  is  a  very  powerful  articula- 
tion, its  strength  being  derived  not  only  from 
the  shape  of  its  component  bones,  but  also  from  the 
unyielding  ligaments  and  many  tendons  that  are 
bound  about  it  like  straps.  Of  the  ligaments,  the 
two  lateral  are  very  strong,  and  have  an  extensive 
hold  upon  the  foot.  The  anterior  and  posterior 
are  extremely  thin  and  insignificant,  although  the 
latter  is  supported  by  the  tendon  of  the  flexor 
longus  hallucis,  which  crosses  it.  When  effusion 
takes  place  into  the  joint,  it  first  shows  itself  in 
front,  beneath  the  extensor  tendons,  and  just  in 
front  of  the  lateral  ligaments.  This  is  due  to  the 
feebleness  of  the  anterior  ligament  and  the  extent 
and  looseness  of  the  synovial  sac  in  relation  with 
that  structure.  More  extensive  effusions  cause  a 
bulging  behind  through  yielding  of  the  thin  pos- 
terior part  of  the  capsule,  and  fluctuation  can 
then  be  obtained  on  either  side  of  the  tendo 
Achillis.  In.no  ordinary  case  can  fluctuation  be 
detected  distinctly  beneath  the  unyielding  lateral 
ligaments.  Moreover,  the  loose  synovial  sac  of  the 
ankle-joint  extends  both  in  front  and  behind 
beyond  the  limits  of  the  articulation,  while 
at  the  sides  it  is  strictly  limited  to  the  joint- 
surfaces. 

The  ankle  is  a  perfect  hinge-joint,  and  per- 
mits only  of  flexion  (plantar-flexion)  and  exten- 
sion (dorsiflcxion).  The  very  slightest  amount  of 


xxvi]  THE  ANKLE-JOINT  619 

lateral  movement  is  allowed  in  extreme  exten- 
sion, when  the  narrower,  or  hinder,  part  of 
the  astragalus  is  brought  into  contact  with  the 
widest,  or  anterior,  part  of  the  tibio-fibular  arch. 
When  obvious  lateral  movement  exists  at  the 
ankle,  the  joint  must  be  the  seat  of  either  injury 
or  disease;  and  it  is  important  not  to  mistake 
the  lateral  movements  permitted  between  certain 
of  the  tarsal  bones  for  movements  at  the  ankle- 
joint.  Movements  are  limited  chiefly  by  the 
muscles  crossing  the  joint,  the  ligaments  becoming 
taut  only  in  extreme  positions,  when  the  natural 
resistance  of  the  muscles  has  been  overcome. 
Muscles  are  the  sentinels  of  joints  (Colin  Mac- 
kenzie). 

Owing  to  its  exposed  position,  this  joint  is 
very  liable  to  become  inflamed  from  injury  or 
other  external  causes.  When  inflamed,  no  dis- 
tortion is,  as  a  rule,  produced,  the  foot  remaining 
at  right  angles  with  the  leg.  It  would  appear 
that  this  position  is  due  to  the  circumstance  that 
the  flexor  and  extensor  muscles  about  balance  one 
another,  and  it  does  not  seem  that  the  capacity  of 
the  joint  is  affected  by  the  posture  of  the  foot. 
The  synovial  cavity  of  the  ankle  is  in  communica- 
tion with  the  inferior  tibio-fibular  articulation. 

In  connexion  with  the  subject  of  "referred 
pains,"  it  should  be  remembered  that  the  nerves 
supplying  the  ankle-joint  bring  that  articulation 
into  relation  with  the  lumbar  segments  of  the 
spinal  cord  through  the  internal  saphenous,  and 
the  sacral  segments  through  the  anterior  tibial 
(deep  peroneal)  nerve. 

Dislocations  sit  the  ankle-joint.— The  foot 
may  be  dislocated  at  the  ankle  in  five  directions, 
which,  placed  in  order  of  frequency,  are:  out- 
wards, inwards,  backwards,  forwards,  and  up- 
wards between  the  tibia  and  fibula.  These  dis- 
locations, which  are  never  purely  in  one  direction, 
are  nearly  always  associated  with  fracture  of 
either  the  "tibia  or  the  fibula,  or  of  both  bones. 

1.     The    lateral     dislocations:     outwards;    in- 


620  THE    LOWER    EXTREMITY  [CHAP. 

wards.  —  These  luxations  differ  somewhat  from 
those  met  with  in  other  joints.  In  the  great 
majority  of  cases  they  consist  of  a  lateral  twisting 
of  the  foot,  of  such  a  kind  that  the  astragalus  is 
rotated  beneath  the  tibio-fibular  arch.  There  is 
no  great  removal  of  the  upper  surface  of  the  astra- 
galus from  that  of  the  tibia,  one  or  other  edge 
of  the  former  bone  being  brought  in  contact  with 
the  horizontal  articular  surface  of  the  latter. 
Although  much  deformity  is  produced,  the  actual 
separation  of  the  foot  from  the  leg  is  not  con- 
siderable. In  some  rare  cases  a  true  lateral  dis- 
location in  the  horizontal  direction  has  been  met 
with. 

These  injuries  are  due  to  sudden  and  violent 
twistings  of  the  foot.  The  luxation  outwards  is 
due  to  forcible  eversion  of  the  foot;  the  luxation 
inwards,  to  violent  inversion. 

It  is  of  interest,  in  the  first  place,  to  note  the 
relation  of  the  fibula  to  injuries  at  the  ankle- 
joint,  especially  as  a  fracture  of  the  lower  end  of 
the  shaft  of  that  bone  may  follow  alike  upon  both 
inversion  and  eversion  of  the  foot.  The  lower  3  or 
4  inches  of  the  fibula  may  be  considered  to  form  a 
lever  of  the  first  order  (Fig.  139,  A).  The  fulcrum 
is  at  the  inferior  tibio-fibular  articulation,  one 
arm  of  the  lever  is  the  malleolus  below  that  joint, 
while  the  other  arm  may  be  regarded  as  formed 
by  the  lower  2  or  3  inches  of  the  shaft  of  the  bone. 
Now,  the  lower  ends  of  the  tibia  and  fibula  are 
bound  together  by  verv  powerful  ligaments,  viz. 
the  anterior  and  posterior  tibio-fibular,  the  trans- 
verse, and  the  inferior  interosseous.  In  no 
ordinary  lesion  about  the  ankle,  whether  fracturo 
or  dislocation,  do  these  ligaments  give  way.  If 
they  should  yield, ^  then  an  anomalous  form  of 
fracture  or  luxation  would  be  produced.  In 
forcible  eversion  of  the  foot,  the  internal  lateral 
ligament  becomes  stretched  and  tears,  the  astra- 
galus is  rotated  laterally  beneath  the  tibio-fibular 
arch  and  is  brought  into  violent  contact  with  the 
end  of  the  outer  malleolus.  This  process  is  pushed 


xxvi]      DISLOCATIONS   AT   ANKLE-JOINT          621 

outwards,  and  acts  as  one  end  of  a  lever.  The 
fulcrum  is  secured  by  the  unyielding  tibio-nbular 
ligaments,  and  the  fibula  breaks  at  the  other  end 
of  the  lever,  a  point  some  2  or  3  inches  above  the 
end  of  the  bone  (Fig.  139,  B).  In  forcible  in- 
version of  the  foot,  the  astragalus  undergoes  a 


Fig.  139. — Diagrams  to  illustrate  the  mechanism  involved 
in  fractures  of  the  lower  end  of  the  fibula. 

A,  Parts  in  normal  position :  a,  tibio-flbular  ligaments  :  &,  external 
lateral  ligament ;  c,  internal  lateral  ligament.  B,  Fracture  of 
tlbula  due  to  e version  of  foot,  c,  Fracture  of  fibula  due  to  inver- 
sion of  foot. 

little  lateral  rotation  in  the  opposite  direction ; 
the  external  lateral  ligament  is  greatly  stretched, 
and  tends  to  drag  the  end  of  the  outer  malleolus 
inwards.  If  the  ligament  yields,  the  case  will 
probably  end  as  a  sprained  ankle,  or  pass  on  to 
a  dislocation  inwards  of  the  foot.  But  if  it 


622  THE    LOWER    EXTREMITY          [CHAP. 

remains  firm,  the  end  of  the  fibular  lever  (the 
tip  of  the  malleolus)  is  drawn  towards  the  middle 
line,  the  fulcrum  is  secured  by  the  tibio-fibular 
ligaments,  and  the  shaft  breaks  at  the  other  end 
of  the  lever,  some  few  inches  above  the  end  of 
the  bone  (Fig.  123,  c).  It  will  be  seen  that  in 
the  fracture  due  to  eversioh  the  upper  end  of  the 
lower  fragment  is  displaced  towards  the  tibia, 
while  in  the  lesion  due  to  inversion  it  is  dis- 
placed from  that  bone.  From  a  careful  examina- 
tion of  all  the  cases  of  fracture  of  the  lower 
end  of  the  fibula  admitted  into  the  London  Hos- 
pital during  the  time  I  (F.  T.)  held  the  post  of 
surgical  registrar  there,  I  was  convinced  that  the 
lesion  is  much  more  frequently  due  to  eversion 
than  to  inversion  of  the  foot.  A  fracture  of  the 
lower  end  of  the  fibula  due  to  simple  inversion 
of  the  foot  is  not  possible  unless  the  external 
lateral  ligament  remains  entire. 

In  the  outward  luxation^  better  known  as 
Pott's  fracture,  the  condition  is  such  as  has  just 
been  described  in  connexion  with  the  effects  of 
eversion  of  the  foot  upon  the  fibula.  That  bone  is 
always  broken  some  2  or  3  inches  above  the  malle- 
olus, the  deltoid  ligament  is  torn,  or  the  tip  of 
the  inner  malleolus  wrenched  off.  Above  all,  the 
tendon-sheaths  are  injured  and  torn.  The  astra- 
galus is  so  rotated  laterally  that  the  foot  is  much 
everted,  its  outer  edge  raised,  while  its  inner 
edge  rests  upon  the  ground.  The  inferior  tibio- 
fibular  ligaments  remain  intact.  If  they  yield,  an 
unusual  form  of  fracture  or  dislocation  is  pro- 
duced, as  already  stated.  Boyer  relates  a  case, 
considered  to  be  unique,  where  the  foot  was  lux- 
ated outwards,  but  without  any  fracture  of  the 
fibula.  That  bone,  however,  had  been  forced  up- 
wards entire,  and  its  head  dislocated  from  the 
articular  facet  of  ^the  tibia.  A  horizontal  disloca- 
tion outwards,  without  rotation  of  the  foot  and 
without  fracture  of  the  fibula,  is  possible  if  the 
inferior  tibio-fibular  ligaments  are  entirely  torn. 

In  Dupuytren's  fracture   (a  rare  injury)   the 


xxvi]     DISLOCATIONS  AT  ANKLE-JOINT         623 

fibula  is  fractured  from  1  to  3  inches  above  the 
malleolus,  the  inferior  tibio-fibular  ligaments  are 
entirely  lacerated,  or  the  portion  of  the  tibia  to 
which  they  are  attached  is  torn  away,  and  remains 
connected  with  the  lower  fragments  of  the  fibula. 
The  foot  is  dislocated  horizontally  outwards,  and 
is  drawn  upwards,  the  extent  of  ^the  upward  dis- 
placement depending  upon  the  height  at  which  the 
fibula  breaks. 

In  the  inward  luxation  the  external  lateral 
ligament  is  torn  or  the  tip  of  the  outer  malleolus 
dragged  away,  the  deltoid  ligament  is  intact,  but 
the  internal  malleolus  is  commonly  broken  by^the 
violence  with  which  the  astragalus  is  brought  into 
contact  with  it.  That  bone  itself  may  be  broken, 
and  is  in  any  case  rotated  laterally,  so  that  the 
foot  is  inverted  and  its  inner  border  much  raised. 
In  all  forms  of  this  dislocation,  whether  simple 
or  complicated,  the  inferior  tibio-fibular  ligament 
remains  intact. 

2.  The  antero  =  posterior  dislocations:  back- 
wards ;  forwards.  —  These  injuries  are  brought 
about  by  great  force  applied  to  the  foot  while  the 
leg  is  fixed,  or  more  commonly  by  sudden^  arrest 
of  the  foot  during  some  violent  impulse  given  to 
the  body,  as  on  jumping  from  a  carriage  which 
is  in  motion.  In  the  luxation  backwards  the 
astragalus  is  displaced  behind  the  tibia,  while  the 
articular  surface  of  the  latter  bone  rests  upon 
the  scaphoid  and  cuneiform  bones.  The  anterior 
and  posterior  ligaments  are  entirely  torn,  and  a 
great  part  also  of  the  two  lateral  bands.  The 
fibula  is  broken  some  2  or  3  inches  above  the  mal- 
leolus, and  there  is  usually  a  fracture  also  of  the 
inner  malleolus. 

The  dislocation  upwards. — In  this  rare  acci- 
dent the  inferior  tibio-fibular  ligaments  are  rup- 
tured, the  two  bones  are  widely  separated  at  their 
lower  ends,  and  the  astragalus  is  driven  up  be- 
tween them.  The  anterior  and  posterior  ligaments 
are  entirely  ruptured,  but  the  lateral  ligaments 
usually  escape  with  but  some  slight  laceration. 


624  THE    LOWER    EXTREMITY  [CHAP. 

The  accident  appears  to  be  generally  caused  by 
a  fall,  the  patient  alighting  flat  upon  the  soles  of 
the  feet. 

Dislocation  of  the  astragalus  (talus).— This 
bone  is  sometimes  luxated  alone,  being  separated 
from  its  connexions  with  the  os  calcis,  the  tibia,  the 
fibula,  and  the  scaphoid  bone.  The  displacement 
may  be  either  forwards,  backwards,  or  lateral. 
The  luxation  forwards  is  by  far  the  most  common 
lesion,  the  next  in  frequency  being  a  luxation 
outwards  and  forwards.  In  these  injuries  the 
interosseous  ligament  between  the  os  calcis  and 
astragalus  is  entirely  torn,  as  are  also  the  greater 
part  of  the  lateral  ligaments  of  the  ankle,  and 
the  various  bands  that  connect  the  astragalus  with 
the  os  calcis  and  scaphoid.  In  all  instances  the 
malleoli  are  brought  nearer  to  the  sole.  Radio- 
graphy has  shown  that  fracture  not  infrequently 
accompanies  dislocation  of  the  astragalus.  When 
it  is  remembered  that  the  astragalus  is  the  key- 
stone of  the  plantar  arch,  and  must  receive  the 
chief  impact  in  all  accidents  which  force  the 
weight  on  the  feet,  the  fracture,  of  its  neck  or 
of  its  body  becomes  intelligible.  In  such  cases 
the  astragalus  has  been  excised  and  a  fair  degree 
of  movement  regained  in  the  new  ankle-joint. 

Subastragaloid  dislocations  of  the  foot. —  In 
these  lesions,  which  are  not  very  uncommon,  the 
astragalus  remains  in  position  between  the  tibia 
and  fibula,  while  the  rest  of  the  foot  is  dislo- 
cated below  that  bone.  The  luxation,  therefore, 
concerns  the  anterior  and  posterior  subastraga- 
loid  joints.  The  foot  may  be  displaced  either 
forwards,  backwards,  or  laterally.  The  forward 
dislocation  is  extremely  rare,  and  the  lateral  luxa- 
tions are  nearly  always  oblique.  In  the  most  usual 
displacements  the  foot  is  dislocated  outwards 
or  inwards,  and  is  at  the  same  time  carried  back- 
wards. 

The  mediotarsal  joint  is  situated  between  the 
head  of  the  astragalus  and  scaphoid  on  the  inner 
side  of  the  foot,  and  the  os  calcis  and  cuboid  on 


xxvi]  ARCHES   OF  THE   FOOT  625 

the  outer.  The  inner  is  part  of  the  anterior  sub- 
astragaloid  joint  (see  p.  627),  while  the  outer  has 
a  separate  synovial  cavity.  It  should  be  noted 
that  the  movements  of  turning  the  toes  either 
in  or  out  take  place  mainly  at  the  hip-joint; 
while  the  turning  of  one  edge  of  the  foot  either 
up  or  down  is  a  movement  that  mostly  concerns 
the  subastragaloid  joints. 

The  foot There  are  two  arches  in  the  foot, 

an  antero-posterior  and  a  transverse. 


Fig.   140. — Antero-posterior  section  of  the  foot. 
(After  Riidinger.) 

1.  The  antero-posterior  arch  has  its  summit  at 
the  astragalus.  It  may  be  considered  as  composed 
of  two  piers.  The  hinder  pier  consists  of  the  qs 
calcis,  the  anterior  pier  of  the  scaphoid,  cunei- 
form, and  metatarsal  bones.  The  astragalus  forms 
the  keystone  of  the  arch,  the  head  of  the  bone 
especially  performing  that  function  (Fig.  140). 

The  foot  rests  upon  the  heel,  the  heads  of  the 
metatarsal  bones,  and  the  outer  margin  of  the  foot 
(Fig.  142).  The  hinder  pier  is  solid,  is  made  up 
of  a  strong  bone,  and  contains  only  one  joint.  It 


626  THE    LOWER    EXTREMITY  [CHAP. 

serves  to  support  the  main  part  of  the  weight  of 
the  body,  and  gives  a  firm  basis  of  attachment 
to  the  muscles  of  the  calf.  The  anterior  part  of 
the  arch,  on  the  other  hand,  contains  many  small 
bones  and  a  number  of  complicated  joints.  It 
serves  to  give  elasticity  to  the  m  foot,  and  to 
diminish  the  effect  of  shocks  received  upon  the 
sole  of  the  foot.  The  comparative  value  of  the 
two  piers  of  the  arch  in  this  latter  respect  can  be 
estimated  by  jumping  from  a  height  and  alight- 
ing first  upon  the  heels  and  then  upon  the 
balls  of  the  toes.  The  inner  part  of  the  arch 
is  much  more  curved  than  the  outer,  and  forms 
the  instep. 

2.  The  transverse  arch  is  most  marked  across 
the  cuneiform  bones.  It  gives  much  elasticity  to 
the  foot  and  affords  protection  to  the  vessels  of 
the  sole.  According  to  Sir  Robert  Jones,  the 
transverse  arch  may  be  strained  or  flattened,  the 
condition  being  accompanied  by  pain  at  the  meta- 
tarso-phalangeal  joints  (metatarsalgia)  when  the 
patient  brings  his  weight  to  bear  on  the  retro- 
digital  pad  of  the  sole.  When  the  patient  com- 
presses the  metatarsals  together  the  pain  is  re- 
lieved, and  it  is_  for  this  reason  that  the  fault  is 
supposed  to  lie  in  a  breakdown  of  the  transverse 
arch.  A  bar  across  the  sole  of  the  shoe  throws 
the  weight  of  the  body  more  on  the  heel,  thus 
relieving  the  strain  on  the  transverse  arch. 

Maintenance  of  the  plantar  arch. — Although 
the  various  bones  are  so  shaped  as  to  fit  into  their 
respective  positions  in  the  arch,  and  are  bound 
together  by  ligaments,  yet  the  maintenance  of 
the  arch  depends  neither  on  the  shapes  of  the 
bones  nor  on  their  ligamentous  attachments,  but 
on  the  living  muscles  which  spring  into  action  the 
moment  the  weight  of  the  body  rests  on  the  feet. 
Three  groups  of  ^  muscles  are  concerned:  (1)  the 
flexor  group,  rising^  from  the  posterior  aspect  of 
the  tibia,  fibula,  and  interosseous  membrane ;  (2)  the 
extensor  group,  rising  from  the  anterior  surfaces 
of  these  structures;  (3)  the  plantar  group,  in  the 


xxvi]  SUBASTRAGALOID  JOINTS  627 

sole  of  the  foot.  It  is  only  when  the  muscles  are 
damaged  or  exhausted  that  a  strain  falls  on  the 
ligaments.  Ligaments  cannot  be  exposed  to  a 
continuous  strain  without  elongating.  As  they 
elongate,  the  bones  accommodate  themselves  to 
the  new  form  of  arch,  which  is  thus  rendered 
permanent. 

The  movements  of  inversion  and  eversion, 
whereby  the  foot  is  adapted  to  the  ground  on 
which  it  treads,  occur  at  the  subastragatoid 
joints.  These  are  two  in  number  :  (1)  the  anterior 
subastragaloid  joint  between  the  head  of  the  astra- 
galus and  three  other  parts — (a)  sustentaculum 
tali;  (b)  inferior  calcaneo-scaphoid  ligament; 
(c)  scaphoid  (Fig.  140);  (2)  posterior  subastra- 
galoid between  the  body  of  the  astragalus  and  os 
calcis.  The  posterior  is  separated  from  the  an- 
terior joint  by  the  inter  osseous  ligament.  A  third 
joint  is  also  concerned  in  these  important  move- 
ments, viz.  that  between  the  os  calcis  and  cuboid. 
The  muscles  which  produce  inversion  are  (1)  tibi- 
alis  posticus,  (2)  tibialis  anticus.  The  first  pro- 
duces inversion  with  plantar  flexion,  the  others 
with  dorsal  flexion.  The  flexor  muscles  of  the 
toes  assist  the  first,  the  extensor  of  the  great  toe 
the  second.  Eversion  is  produced  by  (1)  peroneu? 
longus,  (2)  peroneus  brevis,  (3)  peroneus  tertius, 
(4)  extensor  longus  digitorum.  The  first  pro- 
duces eversion  with  plantar  flexion,  the  other 
with  dorsal  flexion.  Thus  there  are  four  groups 
of  muscles  acting  on  the  subastragaloid  articula- 
tions which  balance  and  determine  the  movements 
of  the  foot,  and  four  positions  in  which  they  may 
fix  the  foot :  (I'j  inversion  with  plantar  flexion 
(talipes  equino-varus) ;  (2)  eversion  with  plantar 
flexion  (talipes  equino-valgus) ;  (3)  inversion  with 
dorsiflexion  (talipes  calcaneo-varus) ;  (4)  eversion 
with  dorsiflexion  (talipes  calcaneo-valgus).  The 
position  assumed  will  depend  on  the  group  or 
groups  of  muscles  which  are  paralysed  or  weak- 
ened. Eversion  is  limited  by  the  structures  along 
the  inner  side  of  the  sole  of  the  foot— the  abductor 


628  THE    LOWER    EXTREMITY  [CHAP. 

hallucis,  plantar  fascia,  the  tibial  muscles,  and 
the  inferior  calcaneo-scaphoid  ligament.  Inver- 
sion is  limited  by  the  peroneal  muscles,  the  liga- 
ments along  the  outer  border  of  the  foot,  and, 
ultimately,  by  the  tuberosity  of  the  scaphoid 
coming  in  contact  with  the  sustentaculum  tali. 
The  movements  of  inversion  and  eversion  corre- 
spond to  supination  and  pronation,  but  in  the 
upper  extremity  these  are  produced  between 
radius  and  ulna,  whereas  in  the  lower  extremity 
they  occur  almost  entirely  between  the  astragalus 
and  the  rest  of  the  foot. 

Club-foot — It  is  usual  to  divide  the  various 
forms  of  talipes,  or  club-foot,  into  four  main 
groups,  viz.:  (1)  T.  equinus;  (2)  T.  calcaneus; 
(3)  T.  varus;  and  (4)  T.  yalgus.  Four  secondary 
forms  result  from  combinations  of  these  prin- 
cipal varieties,  viz.  :  T.  equino-varus,  T.  equino- 
valgus,  T.  calcaneo-varus,  and  T.  calcaneo-valgus. 

1.  Talipes  equinus.     In  this  deformity  the  heel 
is  drawn  up,  and  the  patient  walks  upon  the  balls 
of  the  toes.     The  contracting  muscles  are  those  of 
the    calf,    attached    to    the   tendo    Achillis.      The 
paralysed  muscles  are  the  extensors  of  the  foot. 
There  is  plantar  flexion  and  marked  inversion  of 
the  foot.     In  a  well-marked  case  the  os  calcis  is 
much  raised,  and  may  even  be  brought  in  contact 
with  the  tibia.     The  astragalus  is  displaced  down- 
wards and  projects  upon  the  dorsum.     The  foot 
tends  to  become  more  and  more  inverted,   until 
at  last  the  scaphoid  may  even  touch  the  sustenta- 
culum.      The   ligaments  of  the  sole   are   usually 
much  contracted. 

2.  Talipes  calcaneus.     In  this  form  of  club-foot 
the  toes  are  drawn  up  and  the  patient  walks  upon 
the    heel.     The    contracting    muscles    are    the    ex- 
tensors on  the  anterior  aspect  of  the  limb.     Tho 
os    calcis    is    rendered    more    vertical,    and    the 
astragalus  becomes  so  obliquely  placed  that  part 
of  its  upper  articular  surface  may  project  beyond 
the  tibia  in  a  backward  direction. 

3.  Talipes  varus.    This  is  the  commonest  form. 


xxvi]  GLUB-FOOT  629 

but  it  is  never  pure,  being  usually  associated 
with  inversion  of  the  foot.  Certain  features  of 
the  foetal  foot  are  retained  in  an  exaggerated 
degree.  In  a  well-marked  congenital  case  there 
is  a  threefold  deformity:  (1)  The  heel  is  drawn 
upwards  by  the  muscles  attached  to  the  tendo 
Achillis;  (2)  the  foot  is  inverted  by  the  con- 
traction of  the  tibialis  anticus  and  posticus; 
(3)  the  sole  is  contracted  by  the  flexor  longus 
digitorum  muscle  and  the  shrinking  of  the  plantar 
fascia  and  ligaments.  The  neck  of  the  astragalus 
is  elongated  and  deflected  downwards  and  inwards 
to  a  greater  extent  than  in  the  normal  foot.  In 
the  adult  the  neck  of  the  astragalus  is  deflected 
inwards  to  the  axis  of  its  body  at  an  angle  of  10° ; 
in  the  newly  born  at  an  angle  of  25°;  and  in 
talipes  varus  at  an  angle  of  50°.  The  scaphoid 
is  displaced  upwards  and  inwards,  until  its 
inner  border  often  touches  the  internal  malleolus. 
The  three  cuneiform  bones  follow  the  scaphoid, 
and  the  cuboid  becomes  the  lowest  bone  in  the 
tarsus.  The  outer  border  of  the  cuboid  forms  an 
angle  with  the  os  calcis,  and  the  tendons  of  the 
peroneus  longus  slip  backwards  from  the  groove 
in  the  cuboid  to  lie  on  the  os  calcis.  The  anterior 
border  of  the  internal  lateral  ligament  is  con- 
tracted and  unduly  prominent.  There  is  thus  a 
marked  degree  of  inversion. 

4.  In  talipes  valgus  the  ^ foot  assumes  perma- 
nently the  position  of  eversion.  The  contracting 
muscles  are  the  two  peroriei.  In  a  well-marked 
congenital  case  the  os  calcis  is  found  a  little 
raised  and  the  astragalus  is  displaced  forwards 
and^  downwards.  The  scaphoid  is  so  rotated  that 
its  inner  part  is  depressed  and  its  outer  raised. 
The  internal  portion  of  the  bone  forms  one  of 
the  two  projections  obvious  on  the  inner  side  of 
the  foot,  the  other  prominence  being  formed  by 
the  head  of  the  astragalus.  The  ci>bqid  is  found 
to  be^a  little  rotated  outwards.  The  arch  of  the 
foot  is  lost,  and  all  those  ligamlents  are  stretched 
that  serve  to  support  and  maintain  that  arch. 


630  THE    LOWER    EXTREMITY  [CHAP. 

Of  the  mixed,  or  secondary,  forms  of  talipes 
nothing  need  be  said.  They  are  the  results  merely 
of  a  combination  of  the  primary  varieties. 

As  trouble  is  often  caused  in  talipes  by  pres- 
sure being  brought  to  bear  upon  an  unusual  part 
of  the  foot,  it  is  well  to  note  upon  what  portion 
of  the  member  the  patient  treads  in  the  different 
varieties  of  the  deformity.  In  varus  the  "tread  JJ 
is  mainly  upon  the  outer  side  of  the  fifth  meta- 
tarsal  bone;  in  valgus,  upon  the  internal  malle- 
olus  and  scaphoid;  in  equinus,  upon  the  bases  of 
all  the  toes ;  in  equino-varus,  upon  the  base  of  the 
little  toe;  in  equino-valgus,  upon  the  base  of 
the  great  toe ;  in  all  forms  of  calcaneus,  upon  the 
heel.  In  cases  of  extreme  and  obstinate  club-foot 
of  the  congenital  variety,  wedges  of  bone  are 
sometimes  removed  by  the  operation  known  as 
tarsectomy.  Thus,  in  talipes  equino-varus  the 
base  of  the  wedge  will  be  on  the  outer  side  of 
the  foot,  and  will  be  mainly  represented  by  the 
cuboid;  the  apex  will  be  at  the  scaphoid. 

Flat-foot  and  splay-foot  are  the  names  given 
to  a  deformity  due  probably  to  the  yielding 
of  certain  ligaments,  whereby  the  arch  of  the 
foot  is  lost  and  the  sole  becomes  more  or  less 
perfectly  flat.  The  foot,  at  the  same  time,  is 
abducted,  and  the  outer  border  is  often  a  little 
raised,  so  that  the  patient  walks  mainly  upon 
the  inner  side  of  the  foot.  This  deformity  is  met 
with  in  those  who  stand  a  great  deal,  and  is  the 
direct  result  of  yielding  of  the  muscles  which 
maintain  the  foot  in  a  position  of  inversion— 
especially  the  tibialis  anticus  and  posticus.  It 
is^  only  when  these  muscles  become  exhausted  and 
yield  that  the  ligaments  are  strained  and  elon- 
gated, for  it  may  be  accepted  as  a  law  that  the 
normal  strain  at  a  joint  falls  on  the  muscles,  the 
ligaments  only  coming  into  action  in  limiting 
the  extent  of  movements.  The  inferior  calcaneo- 
scaphoid  ligament  is  normally  lax  in  the  standing 
posture;  the  weight  of  the  head  of  the  astragalus  is 
then  supported  by  the  tibialis  posticus  (Fig.  141). 


xxvi] 


FLAT-FOOT 


631 


As  is  well  known,  the  muscles  of  the  leg  and 
foot  become  more  quickly  exhausted  when  stand- 
ing than  when  walking,  for  in  the  standing 
posture  the  muscles  which  invert  the  foot  are 
maintained  in  a  condition  of  tonus,  whereas  in 
walking  they  have  alternate  periods  of  action  and 
rest.  Hence,  in  those  whose  occupations  entail 
prolonged  periods  of  standing,  the  muscles  which 
maintain  the  inversion  of  the  foot  become  ex- 
hausted— especially  the  tibialis  posticus;  they 
gradually  yield,  and  the  superincumbent  weight 
of  the  body  then  falls  on  the  structures  which 


A/IT  SUP.  An. 
TIBIALIS  ANTICUS, 
.  CUNEIFORM 


1/lEAD   OFASTRACAUU& 

Mr.  CALCAAIEO- SCAP/I  LIQ. 

TuBEROSITr  OF5CAPMOID 


Fig.   141.-  Dissection   of  a  flat  foot  from   the  inner  side. 

limit  eversion  of  the  foot,  especially  the  inferior 
calcaneo-scaphoid  ligament,  on  which  the  head  of 
the  astragalus  then  comes  tojrest  (Fig.  141).  When 
the  weight  falls  on  this  ligament  it  begins  to 
yield;  the  head  of  the  astragalus  is  pressed  for- 
wards, downwards,  and  inwards  by  the  superin- 
cumbent weight,  and  the  foot  beyond  becomes,  as 
a  consequence,  over-extended  and  turned  out  (Fig. 
141).  The  os  calcis  slants  inwards,  and  its  anterior 
end  is  depressed.  The  sustentaculum  tali,  the 
head  of  the  astragalus,  and  the  scaphoid  tubercle 
form  prominences  on  the  inner  side  of  the  foot, 
and  may  rest  on  the  ground  (Fig.  141).  The  long 


632  THE    LOWER    EXTREMITY  [CHAP. 

and  short  plantar  ligaments  also,  which  contribute 
so  much  to  the  maintenance  of  the  arch  of  the 
foot,  in  time  yield,  and  allow  of  a  still  greater 
degree  of  deformity.  There  is  a  stretching  also 
of  the  deltoid  ligament.  In  neglected  cases  the 
distortion  is  rendered  more  or  less  permanent  by 
alterations  in  the  shape  of  the  tarsal  bones,  and 
by  a  contraction  of  such  ligaments  as  have  been 
relaxed  by  the  deformity.  The  scaphoid  and  in- 
ternal cuneiform  become  markedly  wedge-shaped, 
with  the  apices  directed  to  the  dor  sum  of  the  foot 
(Fig.  141). f  The  f90t  being  abducted,  and  its  outer 
border  a  little  raised,  the  peronei  muscles  become 
relaxed,  shortened,  and  contribute  to  the  perma- 
nency of  the  disorder.  It  will  be  understood  that 
the  abnormal  pressure  brought  to  bear  upon  the 
various  tarsal  bones  and  articulations  will  cause 
severe  pain  to  be  often  associated  with  this  affec- 
tion. The  calf  muscles  waste,  owing  to  the  arch 
of  the  foot  having  lost  its  rigidity  and  being  no 
longer  able  to  support  the  weight  of  the  body. 
The  foot  is  the  lever  by  which  the  muscles  of  the 
calf  raise  the  weight  of  the  body  in  the  act  of 
walking.  When  that  lever  loses  its  rigidity  with 
the  collapse  of  the  arch,  the  calf  muscles  can  no 
longer  act;  hence  the  patient  no  longer  steps 
off  his  toes,  but  off  the  inner  side  of  the  heel 
and  foot. 

Imprints  of  normal  feet  vary  much  in  form 
(see  Fig.  142).  Dr.  Lovett  of  Boston  is  of  opinion 
that  the  feet  which  come  in  contact  with  the 
ground  at  only  two  parts — at  the  heel  behind, 
and  along  the  pad  of  the  foot  in  front-^are  those 
which  are  most  prone  to  break  down  (Fig.  142,  A). 
In  flat-foot  tho  inner  border  of  the  foot  also  comes 
in  contact  with  the  ground,  so  that  the  area  be- 
tween the  heel,  the  plantar  pad,  and  the  outer 
margin  of  the  foot,  left  blank  in  the  normal  im- 
print, become  partially  or  completely  filled  up 
(Fis:.  142,  D). 

It  may  be  noted  that  the  mediotarsal  joint, 
which  is  so  conspicuously  involved  in  the  distor- 


XXVI] 


CLAW-FOOT 


633 


tion,  is  supplied  by  the  anterior  tibial,  musculo- 
cutaneous,  and  external  plantar  nerves. 

In  the  condition  known  as  pes  cavus  (claw-foot) 
the  foot  is  flexed  at  the  midtarsal  joint,  the 
plantar  arch  is  increased,  the  heel  is  drawn  up, 
and  the  proximal  phalanges,  especially  of  the 
great  toe,  are  dorsiflexed.  The  condition  develops 
gradually,  and  ultimately  gives  rise  to  great  dis- 
ability; its  cause  is  obscure.  There  is  usually 


A  B  C  D 

Fig.   142. — Various  forms  of  foot-prints. 

A,  Of  normal  foot  with  high  arch. 

B,  „         „         „     also  with  high  arch. 

C,  „         ,,         „     with  low  arch. 

D,  „  flat  foot. 

some  degree  of  weakness  of  the  extensors  of  the 
toes   and   foot. 

The  tarsal  bones,  owing  to  their  spongy  char- 
acter, are  readily  broken  by  direct  violence, 
as  in  severe  crushes.  The  soft  parts  that  cover 
these  bones  being  scanty  upon  the  dorsal  aspect 
of  the  foot,  it  follows  that  these  accidents  are 
often  compound  and  associated  with  much  lacera- 
tion of  the  integuments. 


634  THE    LOWER    EXTREMITY  [CHAP. 

The  tarsal  bone  the  most  frequently  fractured 
is  the  os  calcis.  This  bone  may  be  broken  by  a 
fall  upon  the  heel,  and  in  many  instances  has 
been  tne  only  one  fractured  by  such  an  accident. 
A  few  cases  have  been  recorded  of  fracture  of 
the  calcaneus  by  muscular  violence,  the  muscles 
producing  the  lesion  being  those  attached  to  the 
tendo  Achillis.  Thus,  Sir  A.  Cooper  reports  the 
case  of  a  woman  aged  42,  in  whom  a  large 
fragment  of  the  posterior  part  of  the  os  calcis 
was  torn  away  by  the  muscles  and  drawn  some 
2|  inches  away  from  the  heel.  The  accident  was 
caused  by  her  taking  a  false  step.  Abel  has 
collected  three  cases  of  fracture  of  the  susten- 
taculum  tali.  He  believes  that  this  injury  may 
be  produced  by  falls  upon  the  sole  or  by  extreme 
inversion  of  the  foot,  whereby  the  astragalus  is 
forced  violently  against  the  process.  Skiagrams 
of  the  heel  often  show  a  calcanean  spur,  running 
forwards  from  the  internal  or  external  tuberosity 
of  the  os  calcis  into  the  plantar  fascia.  In  some 
cases  the  presence  of  such  a  spur  is  connected  with 
a  persistent  pain  felt  at  the  inner  side  of  the  heel. 

The  astragalus  alone  may  be  broken  by  a  fall 
upon  the  feet,  and  such  accidents  are  often  associ- 
ated with  fractures  of  both  that  bone  and  the  os 
calcis.  It  must  be  noted,  however,  that  in  a  fall, 
when  the  patient  alights  upon  the  feet,  the  tibia 
and  fibula  are  much  more  likely  to  be  broken  than 
are  the  tarsal  bones,  since  the  bones  of  the  leg 
transmit  the  weight  of  the  body  directly,  whereas 
that  weight  is  much  diffused  and  broken  up  when 
passing  through  the  foot  with  its  many  bones  and 
joints.  Skiagrams  of  the  tarsal  bones  bring  out 
the  lines  or  bony  trabeculse  along  which  such 
forces  are  transmitted.  When  examining  such 
skiagrams,  particularly  in  cases  of  injury,  the 
posterior  process  of  the  astragalus  may  be  seen 
as  if  separated  or  fractured.  It  must  be  re- 
membered that  this  process  is  developed  as  a 
separate  bone  (os  trigonum),  and  in  some  cases 
it  fails  to  fuse  with  the  astragalus. 


xxvi]  OSSIFICATION    OF   TARSUS  635 

Tho  metatarsal  bones  and  phalanges  are  nearly 
always  broken  by  direct  violence.  I  (F.  T.)  had, 
however,  under  my  care  at  the  London  Hospital 
a  man  who  had  broken  the  shafts  of  the  three 
outer  metatarsal  bones  by  simply  slipping  off 
the  edge  of  the  curb.  Since  the  introduction  of 
X-rays  as  a  means  of  diagnosis,  fractures  of  the 
metatarsal  bones,  especially  of  the  fifth,  and  of 
the  phalanges  are  found  to  occur  not  infrequently, 
and  often  as  the  result  of  a  movement  or  acci- 
dent which  seems  totally  insufficient  to  produce 
such  lesions. 

One  or  more  of  the  metatarsal  bones  may  be 
luxated,  or  the  entire  series  may  be  displaced 
upwards,  downwards,  inwards,  or  outwards,' the 
first-named  lesion  being  the  most  common.  This 
is  particularly  the  form  of  lesion  seen  in  the  feet 
of  those  who  have  been  thrown  from  horseback 
and  dragged  by  a  foot  caught  in  the  stirrup. 

Ossification  of  the  tarsus.— At  birth  the  tar- 
sus is  mainly  cartilaginous.  Ossification  begins 
in  the  os  calcis  in  the  sixth  month  and  in  the 
astragalus  in  the  seventh  month  of  foetal  life. 
The  centre  for  the  cuboid  appears  at  birth,  and 
in  the  scaphoid,  the  last  to  ossify,  in  the  third 
year.  It  is  not  until  puberty  that  the  cartilage 
of  the  tarsal  bones  is  completely  ossified.  Like 
the  epiphyses  of  long  bones,  the  tarsal  bones  are 
entirely  formed  in  cartilage,  there  being  no  peri- 
osteal  formation.  Hence  it  is  possible,  as  Ogston 
has  shown,  to  enucleate  the  ossific  centres  from  the 
tarsal  bones  of  children  who  are  the  subjects  of 
club-foot  and,  by  remodelling  the  cartilaginous 
capsules  left  behind,  obtain  new  ossifications  of 
a  more  normal  form. 

Dislocation  of  the  proximal  phalanx  of  the 
great  toe  is  often  very  difficult  to  reduce,  as  is 
also  the  case  in  the  corresponding  luxation  of 
the  thumb.  When  the  displacement  is  dorsal,  the 
difficulty  is  probably  due  to  the  sesamoid  bones, 
which  are  embedded  in  the  glenoid  ligament  or 
fibro-cartilaginous  plate,  and  the  reflex  contrac- 


THE  LOWER  EXTREMITY  [CHAP. 


Fig,  143,  —  Oblique  antero- 
posterior  section  of  foot,  to 
show  the  synovial  cavities 
of  the  tarsus. 


1,  Tibia  ;  2,  fibula  ;  3,  astragalus  ;  4, 
os  calcis  ;  5,  external  lateral 
ligament  ;  6,  internal  lateral 
•  ligament;  7,  interosseous  liga- 
ment between  astragalus  and 
os  calcis  ;  8,  head  of  astragalus  ; 
9,  scaphoid  ;  10,  11,  and  12,  the 
three  cuneiform  bones;  13 
cuboid. 


tion  of  the  groups 
of  muscles  which  find 
an  insertion  on  these 
sesamoids.  The  out- 
ward dislocation  of 
the  proximal  phalanx, 
constituting  the  con- 
dition of  hallux  val- 
gus,  has  been  already 
mentioned  (see  p.  615). 
The  inner  lateral  liga- 
ment of  the  joint  is 
elongated,  while  the 
outer  is  contracted.  In 
hallux  rigidus  this 
joint  is  slightly  flexed 
and  rigid,  due  prob- 
ably to  a  reflex  con- 
traction of  the  short 
muscles  which  act  on 
the  great  toe,  the  cause 
being  usually  some 
lesion  of  the  articular 
surfaces  of  the  joint. 
Obscure  pains  are 
often  associated  with 
the  lesion— a  form  of 
metatarsalgia.  The 
second  toe  is  commonly 
longer  than  the  others, 
and  is  more  liable 
to  assume  the  form 
known  as  "  hammrr- 
toe."  The  proximal 
phalanx  in  such  a  form 
is  extended,  while  the 
middle  is  strongly 
flexed.  The  condition 
is  commonly  inherited, 
and  is  due  to  contrac- 
ture  of  the  interossei 
and  lumbrical  muscles. 


xxvi]        SYNOVIAL  CAVITIES   OF  FOOT 


63? 


There  are  six  synovial  cavities  in  the  foot, 
excluding  that  of  the  ankle-joint,  viz.  one  for  the 
posterior  subastraga- 
loid  joint,  a  second 
for  the  anterior  sub- 
astragaloid,  a  third 
between  the  os  calcis 
and  cuboid,  a  fourth 
between  the  latter 
bone  and  the  two 
outer  metatarsals,  a 
fifth  for  the  joint 
between  the  inner 
cuneiform  and  first 
metatarsal  bones, 
and  a  sixth  for  the 
remaining  articula- 
tions (Fig.  143).  These 
synovial  cavities  tend 
greatly  to  diffuse 
disease  among  the 
various  bones  of  the 
foot  when  once  a  bone 
has  become  inflamed. 
The  best  position, 
therefore,  for  bone 
disease,  with  refer- 
ence to  the  question 
of  extension,  would 
be  in  the  hinder 
parts  of  either  the  os 
calcis  or  astragalus,  •?«•  144,-Syme  s  amputation, 
and  one  of  the  worst 

wrmlrl  V»o  a>  Tlbia  ;  &»  flkula  ;  c,  tibialis  anticus  ; 
d,  extensor  proprius  hallucis  ;  e, 
extensor  communis  digitorum  ; 
/,  peroneus  tertius  ;  (/,  flexor  lon- 
gus hallucis  ;  h,  tibialis  posticus  ; 
i,  flexor  longus  digitorum  ;  j,  pe- 
roneus brevis ;  k,  peroneus  lon- 
gus ;  I,  tendo  Achillis ;  m,  some 
muscles  of  the  sole  that  are  not 
usually  left  in  this  operation  ; 


assumed  by  disease  in- 
volving the  scaphoid 
bone. 

Syme's  amputa- 
tion at  the  ankle 
(Fig.  144).  — In  the 
heel  -  flap  are  cut 
the  integuments,  the 


, 

anterior  tibial  vessels ;  o,  poste- 
rior tibial  vessels ;  p,  posterior 
tibial  nerve. 


638  THE    LOWER    EXTREMITY          [CHAP. 

external  saphenous  nerve  and  vein,  the  peroneus 
longus,  peroneus  brevis,  tibiahs  posticus,  flexor 
us  digitorum,  flexor  longus  Wlucis,  tendo 
AdSSfis,  points  of  origin  of  the  flexor  brevis 
digitorum  and  of  the  two  abductor  muscles,  and 
the  internal  and  external  plantar  arteries  and 

nCrinS'the  dorsal  flap  are  cut  the,  integuments, 
tibialis  anticus,  extensor  communis  digitoruin, 
extensor  proprius  hallucis,  peroneus  tertius,  an- 
terior tibial  vessels  and  nerve,  musculo-cutaneous 
nerve,  and  internal  saphenous  nerve  and  vein 
The  position  of  the  principal  structures  divided 
is  shown  in  Fig.  144.  It  is  not  usual  to  dissect 
up  any  of  the  muscular  tissue  of  the  sole,  as 
shown  in  Agatz's  illustration  It  should.be  noted 
that  the  integuments,  of  the  heel  derive  their 
blood  supply,  which  is  very  free  mainly  from 
the  external  calcaneal  branch  of  the  posterior 
peroneal  artery  on  the  outer  side,  and 
internal  calcaneal  from  the  external  plantar  on 

^V^the'heel  incision  is  carried  sufficiently  far 
back  to  divide  the  trunk  of  the  poster  lor  tibial 
artery,  the  heel-flap  is  deprived  of  the  last-named 
source  of  blood  supply.  The  posterior  tibial 
arterv  bifurcates  upon  a  line  drawn  from  the 
tip  of  the  inner  malleolus  to  the  centre 
convexity  of  the  heel.  , 

The  nerves  supplying  the  integuments  of 
heel    are    the   calcaneal    branch    of    the    external 
saphenous  and  the  calcaneal  and  plantar  cutaneous 
twigs  from  the  posterior  tibial.  .     . 

In  Pirogoff's  amputation  the  os  calcis  is  re- 
tained, but  the  parts  divided  in  the  anterior 
flap  are  the  same  as  in  Syme's  operation.  In 
the  heel  or  sole  flap  the  same  . structures,  also 
are  cut  as  in  the  corresponding  flap  in  a 
Syme,  with  the  exception  that  the  tendo  Achil) 
is  not  divided,  the  flexor  brevis  digitorum, 
abductor  hallucis,  abductor  minimi  digiti,  am 
flexor  accessorius  are  divided  more  extensively 


XXVI] 


CHOPART'S   OPERATION 


039 


and  the  plantar  vessels  are  cut  farther  from  the 
bifurcation. 

Chopart's  operation  is  an  amputation  at  the 
mediotarsal  joint  (Fig.  145).  In  the  dorsal  flap 
are  cut  the  integuments,  the  extensor  communis 
and  brevis 
digitorum,  ex- 
tensor proprius 
hallucis,  tibialis 
anticus,  pero- 
neus tertius  and 

brevis,  the  mus-  , .     — jrrrfa-ry  m  j 

culo  -  cutaneous,  ° — ^™ 

anterior  tibial, 
and  two  saphen- 
ous  nerves,  the 
dorsal  artery, 
and  the  dorsal 
plexus  of  veins. 
In  the  plantar 
flap  are  found 
divided  the  in- 
teguments, plan- 
tar fascia,  flexor 
brevis  digit- 
orum, abductors  Fig.  145.— Chopart's  operation, 
of  the  great  and  (Agatz.) 

little  toes,  flexor  rt)  Astragalus  ;  b,  os  calcis  ;  r,  extensor  pro- 
prius hallucis  ;  d,  tibialis  antictis  ;  c,  ex- 
tensor communis  digitorum ;  /,  peroneus 
longus;  <;,  adductor  minimi  digiti ;  h, 
flexor  brevis  digitorum  ;  ?',  flexor  longus 
digitorum  ;  j,  abductor  hallucis  ;  k,  flex  or 
longus  hallucis  ;  I,  dorsalis  pedis  artery  ; 
w,  internal  plantar  arteiy ;  «,  external 
plantar  artery. 


accessprius,  and 
tibialis  posticus 
tendon.  If  the 
flap  be  well  dis- 
sected up,  parts 
of  the  short 


flexors     of     the 

great  and  little  toes,  the  abductor  hallucis,  and 
transversus  pedis  will  be  found  cut  in  the  flap. 
The  tendons  of  the  long  flexors  of  the  digits 
and  great  toes,  the  peroneus  longus,  and  the 
plantar  vessels  and  nerves  are  also  divided 
(Fig.  145). 

Lisfranc's    operation     consists    in    amputation 


640 


THE    LOWER    EXTREMITY          [CHAP. 


through  the  tarso-metatarsal  line  of  joints  (Fig. 
146).  In  the  dorsal  flap  the  same  structures  are 
divided  as  are  cut  in  the  corresponding  flap  in 

Chopart's  amputa- 
tion. In  the  plantar 
flap  also  the  parts 
divided  are  the  same 
as  in  that  procedure, 
with  the  exception 
k  that  the  flexor  acces- 
sorius  (quadratus) 
&  and  the  tendon  of 
the  tibialis  posticus 
escape  section.  The 
articulations  be- 
tween the  three  outer 
metatarsals  and  the 
corresponding  tarsal 
bones  form  a  line 
sufficiently  straight 
to  be  traversed  by 
the  knife  in  one  cut 
when  once  the  blade 
has  been  introduced. 
The  joint  also  be- 
tween the  first  meta- 
tarsal and  internal 
cuneiform  bones  is 
in  a  straight  line 
and  readily  opened. 
The  most  difficult 
part  of  the  disarticu- 
lation  concerns  the 
separation  of  the 
second  metatarsal 
bone,  which  is  deeply 
lodged  between  the 
tarsal  segments.  The 
chief  bond  of  union  between  this  bone  and  the 
tarsus  is  effected  by  a  strong  interosseous  ligament 
which  passes  between  it  and  the  internal  cuneiform 
(internal  cunei -metatarsal).  In  Fig.  146  the  knife 


Fig.  146. — Lisfranc's  operation. 

(Agatz.) 

a,  b,  c,  Inner,  middle, and  outer  cunei- 
form bones ;  d,  cuboid  ;  e,  /,  the 
metatarsal  bones  ;  g,  tibialis  an- 
ticiis ;  h,  extensor  proprius  hal- 
lucis ;  i,  extensor  communis 
digitorum ;  j,  extensor  brevis 
digitorum  ;  A\  extensor  tendons  ; 
I,  dorsalis  pedis  artery. 


xxvi]  NERVES   OF   LOWER   LIMB  641 

is  placed  in  the  position  required  to  divide  that 
ligament,  and  in  Fig.  147  the  ligament  is  shown. 

In  the  subastragaloid  amputations  a  disarticu- 
lation  is  effected  at  the  subastragaloid  articula- 
tions. The  astragalus  is  the  only  bone  of  the 
foot  left  behind,  and  forms  the  summit  of  the 
stump. 

Nerve  supply  of  the  lower  limb.  —  In 
Fig.  148  is  shown  the  cutaneous  nerve  supply  of 
the  inferior  extremities  on  both  the  anterior 
(extensor)  and  the  posterior  (flexor)  aspect,  and 


MID.  CUNEIFORM 


NT.   CUNEIFORM 


2ND    M  ETA  TAR. 


Fig.   147.— The  ligament  of  Lisfranc  (internal  cunei- 
metatarsal).       (After  Poirier.) 

in  Fig.  149  are  seen  the  cord  segments  from 
which  they  are  derived.  Paralyses  of  the  lower 
limbs  are  common,  but  are.  more  often  due  to 
some  lesion  in  the  inferior  segments  of  the 
spinal  cord  than  to  damage  received  by  any 
one  individual  nerve.  Cases,  however,  are  re- 
corded where  a  single  trunk  has  been  injured 
and  a  limited  form  of  paralysis  has  followed  in 
consequence. 

Paralysis  of  the  anterior  crural  (femoral)  nerve 
has  been  caused  by  injuries  to  the  lower  part 
of  the  vertebral  column  implicating  the  caudJa. 


Fig.  148.— Cutane- 
ous nerve  supply 
of  lower  limb. 

Anterior  aspect.— I,  Ilio-inguinal ;  2,  genito-crural ;  3,  external  cv 
neous  ;  4.  middle  cutaneous  ;  5,  internal  cutaneous  ;  6,  pate) 
plexus  ;  7,  branches  of  external  popliteal ;  8,  internal  sapheno 
9,  musculo-cutaneous;  10,  external  saphenous;  11.  anterior  tib 

Pofstf.rior  aspect.— I,  2,  and  3,  Small  sciatic ;  4,  external  cutaneo 
5,  ifnternal  cutaneous  ;  6,  internal  saphenous  :  7,  branches  of 
ternal  popliteal ;  8,  short  saphenous  :  9,  posterior  tibial :  10, 
teraal  saphenous  ;  11,  internal  plantar  ;  12,  external  plantar. 
642 


Fig.  149.— Showing  the  skin  areas  in  the  lower  extremity 
supplied  by  the  lumbar  and  sacral  segments  of  the 
spinal  cord.  {After  Head.) 

On  each  area  is  indicated  the  segment  of  the  cord  by  which  it  is 
supplied.  For  the  nerves  supplying  each  area,  see  Fig.  148. 

643 


644  THE  LOWER  EXTREMITY  [CHAP. 

equina,  by  fractures  of  the  pelvis,  by  tumours  of 
the  pelvis,  by  psoas  abscess,  by  fractures  and  dis- 
locations of  the  femur,  by  stabs  in  the  region  of 
the  groin,  and  particularly  by  gunshot  injuries 
of  these  parts.  In  this  nerve  lesion  the  patient  is 
unable  to  flex  the  hip  or  to  raise  the  body  from 
the  recumbent  position  (ilio-psoas).  The  adductor 
muscles  may  simulate  the  action  of  the  flexors 
of  the  hip.  The  power  of  extending  the  leg  at 
the  knee  is  lost  (quadriceps  extensor  ci  uris) ;  the 
function  of  the  sartorius  is  destroyed  and  that 
of  the  pectineus  impaired.  Sensation  is  impaired 
in  parts  supplied  by  the  internal  and  middle  cuta- 
neous nerves  and  the  long  saphenous  nerve. 

Paralysis  of  the  obturator  nerve  alone  is  a 
rare  condition,  although  it  may  be  found  associ- 
ated with  a  like  lesion  of  the  preceding  trunk. 
It  may  be  brought  about  by  the  pressure  exer- 
cised upon  the  nerve  in  cases  of  obturator  hernia 
and  by  the  foetal  head  during  delivery.  The 
muscles  implicated  are  the  adductors,  gracilis, 
and  external  obturator.  The  patient  is  unable  to 
press  ^the  knees  together,  or-  to  cross  the  legs. 
Rotation  outwards  is  difficult,  but  sensation  is 
scarcely  affected  in  the  skin  supplied. 

From  its  commencement  the  great  sciatic  nerve 
is  made  up  of  two  distinct  parts,  each  enclosed 
in  its  own  sheath — a  dorsal  or  extensor  part, 
occupying  the  outer  and  deeper  part  of  the  nerve 
and  becoming  the  external  popliteal  (common 
peroneal),  and  a  ventral  or  flexor  part,  becom- 
ing the  internal  popliteal  or  tibial  nerve.  The 
adjacent  parts  of  their  sheaths  form  a  septum 
on  the  great  sciatic  nerve,  but  occasionally  the 
peroneal  and  tibial  sheaths  are  separate  from  the 
beginning.  In  the  middle  third  of  the  sciatic 
trunk  the  fibres  of  both  divisions  undergo  a  rc- 
assprtment — a  re-grouping — thus  forming  a  plexus. 
This  re-grouping  affects  the  motor  fibres  in  par- 
ticular (see  Compton,  Journ.  Anat.,  1917,  li.  103). 
The  various  nerve-bundles  occupy  definite  and 
constant  positions  in  the  great  nerve-trunks. 


xxvi]      PARALYSIS   OF  NERVES   OF  LEG        645 

Paralysis  of  the  internal  popliteal  (tibial)  nerve. 

— There  is  inability  to  flex  the  ankle  and  to  flex 
the  toes  (flexor  longus  digitorum,  flexor  pro- 
ID  rius  hallucis,  tibialis  posticus,  gastrocnemius,  and 
soleus).  The  patient  is  unable  to  stand  upon  the 
toes,  owing  to  loss  of  function  in  the  two  last- 
named  muscles.  The  power  of  inverting  the  foot 
is  impaired  (tibialis  posticus),  and  lateral  move- 
ment in  the  toes  is  lost  owing  to  paralysis  of  all 
the  small  muscles  of  the  sole.  Sensation  is  im- 
paired over  the  plantar  aspect  of  the  toes,  the 
sole,  and  in  part  of  the  lower  half  of  the  back 
of  the  leg. 

In  paralysis  of  the  external  popliteal  (common 
peroneal)  nerve  the  action  of  the  muscles  on  the 
front  of  the  leg  is  lost.  The  foot  hangs  down 
and  the  toes  catch  at  the  ground  in  walking. 
The  foot  can  be  neither  dorsiflexed  nor  everted 
(extensor  communis  digitorum,  extensor  prop  rius 
hallucis,  peroneal  muscles).  Adduction  is  im- 
perfect, owing  to  paralysis  of  the  tibialis  anticus. 
Extension  of  the  toes  is  only  possible  to  the 
slight  extent  effected  by  the  interossei.  The  arch 
of  the  foot  becomes  flattened  owing  to  loss  of 
the  support  furnished  by  the  peroneus  longus. 
Sensation  is  impaired  over  the  front  and  outer 
side  of  the  leg  and  on  the  dorsum  of  the  foot,  and 
also  over  some  part  of  the  back  of  the  leg,  owing 
to  paralysis  of  the  communicans  peronei. 

The  fibres  destined  for  any  particular  muscle 
are  not  assorted  in  one  fasciculus  until  near  their 
point  of  exit  from  the  nerve-trunk ;  hence  a  nerve- 
trunk  such  as  the  internal  popliteal  may  be  partly 
divided  without  any  apparent  effect.  This  cir- 
cumstance is  taken  advantage  of  in  cases  of  in- 
fantile paralysis.  In-  a  case  where  the  external 
popliteal  is  affected,  action  of  the  extensor  mus- 
cles may  be  restored  by  suturing  that  nerve  to 
a  slip  partially  separated  from  the  internal 
popliteal. 

When  the  great  sciatic  nerve  itself  is  paralysed, 
there  will  be,  in  addition  to  the  loss  or  function 


646  THE  LOWER  EXTREMITY 

in  the  two  preceding  nerves,  an  inability  to  flex 
the  knee  owing  to  paralysis  of  the  hamstrings, 
while  rotation  ^of  the  limb  may  be  impaired  by 
loss  of  power  in  the  quadratus  femoris  and  ob- 
turator internus.  Mr.  Sherren  found  that  the 
knee  may  still  be  flexed  in  such  cases  through 
the  action  of  the  gracilis,  and  that  sensation 
is  completely  lost  in  only  part  of  the  sole  of 
the  foot. 

A  knowledge  of  the  segments  of  the  cord 
from  which  the  nerves  of  the  lower  limb  arise 
often  assists  the  surgeon  in  localizing  certain 
lesions.  Section  of  a  nerve-root,  as  may  happen 
in  fracture  of  the  spine,  or  destruction  of  its 
centre  in  the  spinal  cord,  gives  rise  to  paralysis 
in  a  definite  group  of  muscles  and  anaesthesia 
of  a  certain  area  of  skin.  The  skin  areas 
supplied  by  the  lumbar  and  sacral  segments  are 
shown  in  Fig.  149,  and  these  segments,  accord- 
ing to  Kocher,  innervate  the  following  groups  of 
muscles  :  Third  lumbar,  the  psoas,  iliacus,  pec- 
tineus:  sartorius  and  adductors;  fourth  lumbar, 
quadriceps  extensor  cruris;  fifth  lumbar,  gluteus 
medius  and  minimus,  tensor  fasciae  femoris  and 
hamstrings;  first  sacral,  gluteus  maximus,  short 
external  rotators  of  the  hip-joint,  peronei,  exten- 
sors of  the  toes  and  flexors  of  the  ankle;  second 
sacral,  gastrocnemius,  soleus,  long  flexors  of  the 
toes  and  extensors  of  the  ankle-joint  and  muscles 
of  the  sole. 

For  the  principles  underlying  the  distribution 
of  the  limb  nerves  the  reader  is  referred  to 
p.  335.  In  the  lower  as  in  the  upper  limbs  there 
is  ^a  considerable  variation  as  to  the  segmental 
origin  of  the  nerves,  the  variations  tending  towards 
either  a  prefixed  or  a  postfix'ed  type  (see  p.  335). 


PART  VI 
THE  SPINE  AND  SPINAL  CORD 

CHAPTER   XXVII 
THE  SPINE 

THE  vertebral  column  combines  in  a  remarkable 
way  many  very  different  and  complicated  func- 
tions. It  acts  as  the  central  pillar  of  the  body, 
and  as  the  column  that  supports  the  weight  of 
the  head.  It  connects  the  upper  and  lower  seg- 
ments of  the  trunk.  It  gives  attachments  to  the 
ribs.  It  has  the  property^of  mitigating  the  effects 
of  shocks  that  are  transmitted  from  various  parts 
of  the  body.  It  permits,  to  a  wonderful  degree,  of 
a  number  of  most  complicated  movements.  It 
forms  a  solid  tube  for  the  reception  of  the 
spinal  cord.  Finally,  it  represents  a  triumph  in 
balancing,  for  in  the  erect  position  twenty-four 
vertebral  segments  are  balanced  one  upon  another 
by  a  system  of  active  muscles,  the  whole  resting 
on  the  sacrum  as  a  base  and  supporting  the  skull 
as  a  crown. 

It  owes  much  of  its  elasticity,  and  of  its  power 
of  breaking  up  divers  forces  communicated  to 
it,  to  its  curves.  Of  the  four  curves,  two,  the 
dorsal  and  sacral,  are  primary  and  are  due  to 
the  formation  of  the  thoracic  and  pelvic  cavities, 
647 


648  THE  SPINE  AND  SPINAL  CORD      [CHAP 

the  curvatures  being  permanent  owing  to  the 
shape  of  the  vertebrae  entering  into  their  forma- 
tion. The  other  two,  the  cervical  and  lumbar, 
are  compensatory  curves,  and  depend  mainly 
upon  the  action  of  muscles  and  the  shape  of 
the  intervertebral  discs.  The  dorsal  and  sacral 
curves  appear  in  foetal  life;  the  lumbar  and 
cervical  curves  appear  after  birth,  following  the 
assumption  of  the  erect  position.  The  infant's 
spine  appears  straight.  The  only  marked  curve 
seen  in  the  back  of  the  young  child  is  a  general 
curving  of  the  column  backwards,  a  kyphosis. 
When  the  infant  is  first  encouraged  to  sit  erect, 
this  is  the  outline  assumed  by  the  spine,  and  in 
some  weakly  children,  and  especially  in  those 
afflicted  with  rickets,  this  curvature  is  often  very 
pronounced.  The  intervertebral  discs,  twenty- 
three  in  number,  make  up  nearly  one-fourth  of  the 
entire  length  of  the  spine.  If  the  discs  be  removed, 
and  the  vertebrae  be  articulated  in  the  dry  state, 
the  cervical  and  lumbar  convexities  almost  dis- 
appear, and  the  column  tends  to  present  one  great 
curvature,  the  concavity  of  which  is  forwards,  and 
the  most  marked  part  of  which  corresponds  to 
a  point  just  below  the  middle  of  the  dorsal  region. 
This  somewhat  resembles  the  curve  seen  in  the 
spines  of  the  aged,  and  in  such  individuals  it  may 
be  to  no  small  extent  due  to  the  shrinking  of  the 
intervertebral  discs. 

It  is  by  means  of  the  discs  that  the  move- 
ments of  the  spine  are  in  the  main  permitted, 
and  it^will  be  found  that  they  are  most  developed 
in  regions  where  most  movement  is  allowed.  They 
act  also  as  springs  in  giving  elasticity  to  the 
column,  and  in  economizing  muscular  action, 
while  at  the  same  time  they  play  the  part  of 
buffers  in  modifying  the  effect  of  shocks  trans- 
mitted along  the  spine. 

Although  the  motion  permitted  between  any 
two  individual  vertebrae  is  not  extensive,  yet  the 


degree   of   movement   capable   of   being   exercised 
in  the  column  as  a  whole  is  considerable. 


While 


xxvn]     MUSCLES   ACTING   ON  THE   SPINE      649 

lateral  movements  and  those  of  flexion  and  ex- 
tension are  restricted  in  the  dorsal  region,  those 
of  rotation  are  free ;  hence  scoliosis  of  the  spine 
is  most  marked  in  this  region.  Movements  from 
back  to  front  (flexion  and  extension)  and  from 
side  to  side  (lateral  flexion)  are  freest  in  the 
cervical,  dorso-lumbar  and  lumbar  regions.  From 
a  surgical  point  of  view  the  weakest  part  of 
the  spinal  column  is  between  the  ninth  dorsal 
and  third  lumbar  vertebrae.  Here  side-to-side 
and  back-to-front  movements  occur  most  freely; 
above  this  region  the  spine  is  supported  by  the 
thorax;  below,  the  intervertebral  discs  are  larger 
and  stronger,  and  the  supporting  ligaments  and 
muscles  better  developed. 

It  is  impossible  to  insist  too  strongly  on  the 
fact  that  the  muscles  of  the  back  and  trunk 
are  the  sole  agents  in  maintaining  the  spine 
erect.  The  moment  they  are  thrown  out  of  action 
the  spinal  column  loses  its  rigidity  and  collapses. 
All  four  groups  of  muscles  which  act  on  the  spine 
are  concerned  :  the  extensors  (erector  spinse) ; 
the  flexors  (longais  colli,  scaleni,  quadratus  lum- 
borum) ;  the  lateral  flexors  (erector  spinse,  quad- 
ratus lumborum,  internal  and  external  oblique) ; 
rotators  (external  and  internal  oblique,  multi- 
fidus  spinse,  semispinalis,  and  rotatores  spinse). 
By  these  muscles  the  vertebrse  are  maintained 
balanced  on  their  intervertebral  discs,  one  above 
the  other.  The  ligaments  are  slack,  and  the  sur- 
faces of  the  articular  processes  are  in  only  light 
contact.  When  the  muscles  approach  exhaustion, 
owing  to  prolonged  maintenance  of  the  erect  pos- 
ture, partial  relief  may  be  obtained  by  allowing 
a  certain  degree  of  rotation  and  lateral  flexion 
to  take  place.  Thereby  the  articular  processes  are 
brought  into  firm  contact,  the  ligaments  become 
somewhat  tightened,  and  a  certain  degree  of  pas- 
sive support  is^  obtained.  School  children,  for 
instance,  after  sitting  some  time  with  their  bodies 
erect,  place  an  arm  on  the  desk  and  rotate  the 
body  until  the  vertebrse  are  partly  locked.  In 
v* 


650  THE  SPINE  AND  SPINAL  OORD      [CHAP 

this  posture  the  muscles  are  rested,  but,  if  the 
position  be  much  indulged  in,  the  muscles  become 
weakened  in  their  action,  and  the  spine  may 
assume  permanently  a  partial  scoliosis. 

Scoliosis.  —  In  very  few  people  do  the  spines 
of  the  vertebrae  lie  in  a  perfectly  straight  line 
down  the  back.  There  is  commonly  a  slight  de- 
gree of  lateral  curvature.  If  the  pelvis  be  tilted 
laterally,  as  when  the  limbs  are  unequal  in  length, 
a  compensatory  lateral  curve  is  produced.  In 
scoliosis,  lateral  curvature  is  combined  with  a 
rotation  of  the  vertebrae,  the  spinous  processes 
turning  to  one  side  of  the  median  line  and  the 
bodies  to  the  opposite.  It  is  a  disease  of  ado- 
lescents, due  to  a  weakness  of  the  spinal  muscles, 
which  are  unable  to  maintain  the  vertebrae 
in  the  position  necessary  for  the  erect  posture. 
Each  vertebra  is  provided  with  three  levers,  a 
posterior  (the  spinous  process)  and  two  lateral 
(the  transverse  processes  and  attached  ribs).  The 
erector  spinae  acts  on  the  lateral  levers;  the 
multifidus  spinae  and  muscles  for  the  upper  ex- 
tremity on  the  posterior.  It  is  through  train- 
ing these  muscles  by  suitable  exercises  that  the 
vertebrae  can  be  restored  to,  and  maintained  in, 
their  normal  positions.  The  ribs  form  the  most 
powerful  spinal  levers;  in  exercises  to  restore 
deformities  of  the  spine  this  should  be  kept  in 
mind.  All  the  respiratory  muscles  act  indirectly 
through  the  costal  levers  on  the  spine ;  hence 
respiratory  exercises  are  suitable  for  the  treat- 
ment of  postural  defects.  Dr.  Halls  Dally  has 
shown  that  in  all  forms  of  breathing,  and  es- 
pecially in  forced  respiration,  spinal  movements 
are  always  present. 

Sprains  of  the  vertebral  column.— The 
many  joints  and  ligaments  of  the  part,  and  the 
varied  and  violent  movements  to  which  it  may  be 
exposed,  render  it  ^  very  liable  to  be  the  seat  of 
sprains.  These  injuries,  however,  cannot  reach 
any  great  magnitude,  for  so  closely  are  the  in- 
dividual vertebrae  articulated  that  any  force 


xxvn]  VERTEBRAL  SPRAINS  651 

severe  enough  to  produce  other  than  slight  tearing 
of  the  ligaments  will  tend  to  cause  a  fracture  or 
dislocation  of  the  bones. 

Sprains  are  most  commonly  met  with  in  the 
cervical  and  lumbar  segments  of  the  spine.  This 
localization  is  due  to  the  mobility  of  these  parts, 
and  to  their  tendency  to  diffuse  any  violence 
transmitted  to  them,  and  so  to  render  it  more 
general.  For  it  is  to  be  noted  that  the  more 
localized  an  injury,  the  more  likely  it  is  to  pro- 
duce a  fracture  or  dislocation  rather  than  a 
sprain. 

In  the  cervical  region,  also,  the  tendency  to 
sprain  is  increased  by  the  near  articulation  of  the 
column  with  the  head,  and  the  possibility  of  any 
violence  applied  to  the  skull  being  transmitted 
to  the  spine.  Since  the  introduction  of  Rontgen 
•rays  in  the  diagnosis  of  such  injuries  it  has 
become  apparent  that  many  lesions  formerly 
regarded  as  sprains  are  really  fractures  of  the 
body  of  the  vertebra  or  of  the  neural  arch 
(Sherren). 

Sprains  of  the  spine  are  'not  apt  to  be  asso- 
ciated with  the  external  evidences  of  ecchymosis, 
since  between  the  skin  and  the  column  there  inter- 
vene not  only  many  layers  of  muscles,  but  also 
dense  expansions  of  fascia. 

It  has  already  been  pointed  out  that  sprains  in 
the  loin,  produced  by  severe  bending  forwards 
of  the  column,  may  be  associated  with  some 
damage  to  the  kidney  and  consequent  hsema/turia 
(p.  448). 

A  sprained  back  is  often  the  seat  of  a  con- 
siderable degree  of  pain  and  stiffness,  which  per- 
sists long  after  the  immediate  effects  of  the  lesion 
must  have  passed  away.  Such  a  condition  may  be 
understood  by  noticing  that  the  column  presents 
a  vast  number  of  separate  articulations,  each 
provided  with  cartilage,  synovia!  membrane,  and 
capsular  ligaments.  These  joints  have  no  quali- 
ties that  exempt  them  from  the  common  evils 
incident  to  sprains  of  more  superficial  articula- 


652          THE  SPINE  AND  SPINAL  CORD      [CHAP. 

tions;  and  there  is  little  doubt  that  the  long-felt 
pain  and  inconvenience  often  depend  upon  some 
synovitis  of  the  vertebral  joints.  In  a  few  cases 
this  synovitis  has  gone  on  to  suppuration,  and 
in  one  instance  at  least  the  pus  so  formed  found 
its  way  into  the  spinal  canal  and  induced  some 
mischief  in  the  cord.  The  muscles,  too,  are 
frequently  ruptured,  and  processes  of  the  vertebrae 
may  be  torn  away. 

In  some  cases  the  transverse  processes  of  the 
fifth  lumbar  vertebra  are  massive  and  come  in 
contact  with  the  base  of  the  sacrum  when  the 
body  is  moved  sideways.  Such  movements  may 
be  accompanied  by  pain  and  may  be  the  cause 
of  certain  conditions  of  weakness  in  the  lumbar 
region  of  the  spine  (Goldthwaite). 

Fractures  and  dislocations  of  the  spine.— 
The  effects  of  violence  applied  to  the  column  are 
much  diminished  by  the  general  elasticity  of  the 
spine,  by  its  curves,  and  by  the  circumstance  that 
it  is  composed  of  a  number  of  separate  segments. 
Each  vertebra  meets  the  one  immediately  above  or 
below  it  at  three  points  of  contact,  the  body  and 
the  two  articulating  processes.  The  bodies  are 
separated  by  the  intervertebral  disc,  which  acts 
as  an  excellent  spring  or  buffer  in  modifying  the 
effects  of  violence.  The  articulating  processes  are 
more  or  less  wedge-shaped,  the  thin  edge  of  one 
being  applied  to  the  base  of  the  other.  When  a 
force  that  tends  to  compress  the  vertebrae  together 
is  applied  to  the  column,  the  bases  of  the  two 
wedges  are  brought  into  closer  ^and  closer  rela- 
tion, and  thus  an  increasing  resistance  is  offered 
to  the  compressing  power. 

The  parts  of  the  spine  most  liable  to  injury  are 
(1)  the  atlan to-axial,  (2)  the  cervico-dorsal,  and 
(3)  the  dorso-lumbar.  In  the  atlanto-axial  region 
the  parts  not  only  enjoy  a  very  considerable  degree 
of  movement  but  are  very  directly  influenced  by 
many  forms  of  violence  applied  to  the  head.  In 
the  two  other  regions  it  will  be  noted  that  a 
flexible  part  of  the  spine  joins  a  comparatively 


xxvii]  INJURIES   TO   THE   SPINE  653 

rigid  segment  of  it,  and  thus  violence  applied  to 
the  column  in  either  of  these  districts  is  apt  to  be 
concentrated  rather  than  diffused.  The  sternum 
and  ribs  act  as  a  splint  to  the  dorsal  part  of  the 
column.  The  mechanism  is  in  a  way  illustrated 
by  the  circumstance  that  a  fishing-rod  when  it 
snaps  commonly  breaks  near  a  joint,  that  is  to 
say,  at  a  spot  where  a  flexible  segment  of  the  rod 
meets  a  less  elastic  portion.  In  the  dorso-lumbar 
region,  moreover,  the  vertebrae,  although  they 
have  to  support  almost  as  much  weight  as  have 
those  of  the  lumbar  region  proper,  are  yet  dispro- 
portionately small  in  size.  Being  placed,  also, 
near  the  middle  of  the  column,  they  can  be  in- 
fluenced on  all  sides  by  a  powerful  amount  of 
leverage.  The  gravity  of  all  injuries  to  the  spine 
depends  upon  the  risk  of  damage  to  the  cord  en- 
closed in  the  column.  Apart  from  this  complica- 
tion, fractures  and  dislocations  in  this  region  are 
apt  to  do  well,  and,  if  the  patient  survive,  the 
former  lesions  nearly  always  heal  readily. 

The  position  of  the  cord  within  the  vertebral 
canal  and  the  arrangement  of  its  membranes  are 
such  as  to  present  many  facilities  for  escaping 
injury  from  violence.  These  will  be  dealt  with 
subsequently  in  speaking  of  the  cord  itself.  It 
may,  however,  be  noted  here  that  the  construction 
of  the  vertebras,  and  their  relation  to  one  another, 
are  of  a  character  to  afford  much  protection  to  the 
cord,  even  in  cases  where  they  themselves  are  ex- 
tensively damaged.  "  Being  lodged  in  the  centre 
of  the  column,  it  (the  cord)  occupies  neutral 
ground  to  forces  which  might  cause  fracture.  For 
it  is  a  law  in  mechanics  that  when  a  beam,  as  of 
timber,  is  exposed  to  breakage,  and  the  force 
does  not  exceed  the  limits  of  the  strength  of 
the  material,  one  division  resists  compression, 
another  laceration  of  the  particles,  while  the 
third,  between  the  two,  is  in  a  negative  condi- 
tion" (Jacobson,  Holmes's  "System").  Now,  it 
happens  that  fractures  of  the  spine  are  most  often 
due  to  violence  that  bends  the  column  forwards. 


654  THE  SPINE  AND  SPINAL  OORD      [CHAP. 

The  anterior  segment,  in  such  a  case,  will  be  sub- 
ject to  compression,  the  posterior  to  laceration, 
and  the  intermediate  portion  will  be  in  a  neutral 
condition.  When  the  spine  is  examined,  it  will 
be  found  that  its  anterior  part,  composed  of  the 
large  cancellous  bodies,  is  excellently  adapted  to 
resist  the  effects  of  compression,  while  its  pos- 
terior parts,  composed  of  slighter  and  more  com- 
pact bones  and  surrounded  by  many  strong  liga- 
ments, are  well  arranged  to  resist  the  effects  of  a 
tearing  force.  The  spinal  cord,  situated  between 
these  two  divisions,  occupies  the  position  of  least 
danger. 

The  vertebrae  may  be  fractured  without  being 
dislocated,  but  a  dislocation  without  a  fracture 
seldom  occurs. 

It  would  appear,  indeed,  that  a  luxation  of  the 
spine,  with  no  fracture  of  the  bone,  cannot  occur 
in  either  the  dorsal  or  lumbar  regions.  Jacobson, 
in  the  essay  above  referred  to,  writes :  "  I  believe 
I  am  correct  in  stating  that  there  is  no  case 
recorded,  and  thoroughly  verified,  in  recent  years, 
of  dislocation  of  the  lumbar  or  dorsal  vertebrae  un- 
accompanied with  any  fracture  of  the  body,  trans- 
verse or  articular  processes."  Dislocation  without 
fracture  is,  however,  met  with  in  the  cervical  spine. 
When  it  occurs  it  most  often  involves  the  fifth 
vertebra,  which,  with  the  rest  of  the  column  above 
it,  is  displaced  forwards  and  downwards.  The  luxa- 
tion is  usually  bilateral  and  incomplete,  and  is  the 
result  of  a  forcible  bending  of  the  head  and  upper 
p^art  of  the  spine  forwards  and  downwards.  When 
situated  high  up  the  displacement  may  be  appre- 
ciated by  an  examination  of  the  part  through  the 
pharynx.  The  degree  of  deformity  may  be  slight, 
and  the  spinal  injury  overlooked.  The  paralysis 
below  the  level  of  the  dislocation  may  be  in- 
complete; so  that  a  diagnosis  of  injury  to  the 
brachial  plexus  may  be  made  when  it  is  really 
one  of  the  spine  and  cord  (Sherren).  In  the 
complete  bilateral  dislocation  the  cord  is  usually 
hopelessly  crushed.  These  luxations  have  been 


xxvn]   FRACTURE-DISLOCATION   OF  SPINE    655 

reduced  by  forcible  extension,  although  the  circum- 
stances under  which  such  a  procedure  is  advisable 
are  neither  frequent  nor  very  distinctly  marked. 

Since,  in  severe  injuries,  dislocation  and  frac- 
ture are  so  usually  associated,  it  is  common  to 
deal  with  these  lesions  under  the  title  of  fracture- 
dislocation.  They  may  be  due  (a)  to  indirect, 
(6)  to  direct  violence. 

(a)  The  injuries  from  indirect  violence  are 
by  far  the  more  common.  They  are  due  to  a 
violent  bending  of  the  head,  or  of  the  spine 
above  the  seat  of  lesion,  forwards  and  down- 
wards. Thus,  the  cervical  spine  has  been  more 
than  once  broken  by  a  "  header "  into  shallow 
water;  these  accidents  were  particularly  common 
in  the  first  summer  of  the  Great  War,  when  Eng- 
lish soldiers  undergoing  training  were  bathing  in 
unfamiliar  shallow  pools.  In  all  cases  the  dis- 
location occurred  in  the  lower  cervical  region, 
where  the  flexible  cervical  met  the  more  rigid 
dorsal  segment  of  the  spine.  In  several  cases 
death  was  caused  by  the  careless  handling  of  the 
unconscious  patient,  for  the  cervical  part  of  the 
cord  then  lay  unprotected  and  subject  to  injury 
during  any  unguarded  movement.  The  dorsal 
vertebrae  have  been  fractured  and  displaced  by 
the  acute  bending  of  the  column  produced  by  a 
heavy ^  sack  falling  upon  the  back  of  the  neck. 

This  form  of  injury  is  most  commonly  met  with 
in  the  cervical  and  upper  dorsal  regions.  These 
parts  of  the  column  possess  great  mobility,  the 
bodies  that  compose  them  are  not  large,  and  are 
influenced  by  violence  applied  to  the  head.  In  a 
well-marked  case  there  is  some  crushing  of  the 
vertebrae  involved,  and  the  usual  d^rmity  de- 
pends upon  the  centrum  above  sliding  down- 
wards and  forwards  upon  the  centrum  below. 
Complete  displacement  of  any  two  vertebrae  from 
one  another  is  prevented  by  a  locking  of  the  pos- 
terior processes.  ^  In  some  <  cases  the  luxation  is 
complete,  a  condition  that  is  least  frequently  met 
with  in  the  lumbar  spine. 


656          THE  SPINE  AND  SPINAL  CORD      [CHAP. 

In  the  cervical  and  dorsal  regions  the  parts, 
after  the  dislocation,  may  often  be  returned  to 
their  normal  position;  but  in  the  loins  this  replace- 
ment is  usually  impossible,  owing  to  the  locking 
of  the  large  and  powerful  articular  processes. 
In  the  neck  the  laminae  and  spines  may  be  frac- 
tured, while  the  articulating  processes,  being 
broad  and  nearly  horizontal,  usually  escape,  even 
when  there  is  much  displacement  of  the  parts.  In 
the  dorsal  spine  the  laminae  and  articular  pro- 
cesses are  always  torn  when  displacement  occurs. 
In  the  lumbar  region  the  articular  processes 
usually  escape  fracture  although  they  are  vio- 
lently torn  asunder.  In  all  cases  there  is  more  or 
less  laceration  of  the  intervertebral  discs,  and  the 
supraspinous,  interspinous,  and  capsular  liga- 
ments are  torn,  as  are  also  the  ligamenta  subflava. 
When  the  bodies  are  much  crushed  and  displaced 
the  anterior  and  posterior  common  ligaments  are 
commonly  ruptured. 

(6)  In  the  fracture-dislocations  due  to  direct 
violence  the  lesion  may  be  at^  any  part  of  the 
spine.  Some  form  of  direct  violence  is  applied 
to  the  back,  and  the  column  tends  to  become  bent 
backwards  at  the  spot  struck.  In  the  previous 
class  of  injuries  it  will  be  noted  that  the  anterior 
segments  of  the  vertebrae  suffer  compression,  while 
the  posterior  suffer  from  the  effects  of  laceration 
and  a  tearing  asunder  of  their  parts.  In  lesions 
due  to  direct  violence  the  circumstances  of  the  in- 
jury are  reversed;  the  posterior  segments  tend  to 
be  crushed  together,  while  the  bodies  on  the  front 
of  the  spine  are  separated. 

Much  displacement  is  very  rarely  met  with  in 
this  form  of  accident^  To  produce  separation 
of  the  vertebrae  the  violence  must  be  extreme, 
and  as  a  rule  the  force  expends  itself  upon  a 
crushing  of  the  hinder  portions  of  the  spinal 
segments. ^  It  follows  from  this  that  injury  to 
the  cord  is  less  common  and  less  severe  in  lesions 
due  to  direct  violence  than  in  those  due  to  indirect 
violence.  In  the  atlanto-axial  region  the  atlas 


xxvn]  LAMINEGTOMY  657 

and  occipital  bone  have  been  dislocated  from  one 
another  by  direct  violence,  although  the  most 
frequent  lesion  is  a  dislocation  of  the  former 
forwards  upon  the  axis,  a  lesion  usually,  if  not 
always,  associated  with  fracture  of  the,  odontoid 
process.  The  transverse  process  of  the  atlas  can 
be  felt  between  the  mastoid  process  and  the  ja\v 
when  it  is  in  normal  position  (E.  Corner). 

The  spinous  processes  may  be  broken  off  as  a 
result  of  well-localized  blows  or  of  sudden  strains 
or  contractions  due  to  muscular  action.  The 
prominent  spines  in  the  lower  cervical  region 
and  the  long  processes  of  the  dorsal  tract  of 
the  column  are  those  that  usually  suffer.  The 
lumbar  spines  are  less  frequently  broken,  being 
comparatively  small  and  well  protected  by  the 
great  muscles  of  the  back. 

Since  the  introduction  of  X-rays  as  an  aid 
to  diagnosis  it  has  been  found  that  in  falls, 
and  as  a  result  of  sudden  muscular  effort,  it  is 
not  uncommon  for  the  transverse  processes  of  the 
lumbar  vertebrae  to  be  broken.  In  this  connexion 
it  should  be  remembered  that  it  is  not  un- 
common for  a  costal  process  to  be  attached  to 
the  first  lumbar  vertebra — a  lumbar  rib — thus 
simulating  a  fracture  of  a  transverse  process. 
In  great  exertions,  as  in  lifting  or  carrying  heavy 
weights  on  the  back,  the  psoas  and  quadratus 
lumborum  may  actually  fracture  the  transverse 
processes  of  the  lumbar  vertebrae  to  which  they 
are  attached. 

In  some  instances  of  fracture-dislocation  .and 
of  fracture  alone  the  spine  has  been  trephined,  or 
rather  portions  of  the  laminas  and  spinous  pro- 
cesses have  been  resected  (laminectomy).  By  this 
means  the  spinal  canal  has  been  freely  opened  up, 
effused  blood  has  been  allowed  to  escape,  and  the 
cord  has  been  freed  from  pressure.  The  laminae 
are  divided  as  near  the  transverse  process  as  pos- 
sible, and  the  tough  ligamenta  subflava  require 
careful  division. 

The    column    is    reached    through    a    median 


658          THE  SPINE  AND  SPINAL  CORD 

incision,  and  the  great  muscular  masses  are  cleared 
from  the  spinous  processes  and  laminae  on  either 
side.  The  wound  being  nearly  median,  the  bleed- 
ing is  not  excessive.  The  dorsal  spinal  plexus  of 
veins  lies  along  the  spines  and  over  the  laminre. 
On  the  deep  surface  of  the  laminae  lie  the  pos- 
terior longitudinal  spinal  veins. 

This  operation  has  also  been  carried  out  with 
success  in  cases  of  paralysis  due  to  pressure 
upon  the  cord  by  displaced  bone  or  inflammatory 
exudations  in  caries  of  the  spine  (Pott's  disease). 
It  has  to  be  noted,  however,  in  the  last-named 
class  of  case,  that  the  condition  exhibits  a  ten- 
dency to  spontaneous  cure. 


CHAPTER   XXVIII 
THE    SPINAL    CORD 

THE  spinal  cord  is,  in  the  adult,  about  18  inches 
in  length,  and  extends  from  the  lower  margin 
of  the  foramen  magnum  to  the  lower  edge  of 
the  body  of  the  first  lumbar  vertebra.  In  some 
cases,  particularly  in  women  and  children,  it  ends 
at  the  second  or  even  third  lumbar,  and  in  other 
instances  at  the  last  dorsal  vertebra.  It  is  to  be 
noted  also  that  in  flexion  of  the  spine  the  cord  is  a 
little  raised.  When  the  body  is  bent  and  the  arms 
are  stretched  out  the  lumbar  part  is  raised  10  mm. 
In  the  earlier  months  of  foetal  life  the  medulla 
spinalis  occupies  the  whole  length  of  the  verte- 
bral canal,  but  after  the  third  month  the  canal 
and  lumbar  and  sacral  nerves  grow  so  much 
faster  than  the  cord,  that  by  the  time  of  birth 
it  reaches  no  farther  than  the  third  lumbar  ver- 
tebra. Obviously  it  is  a  great  advantage,  in  cases 
of  injury,  that  the  spinal  cord  does  not  occupy 
that  part  of  the  vertebral  pillar  which  joins  the 
base  of  the  column,  and  which  not  only  permits 
of  considerable  movement,  but  is  liable  also  to 
frequent  wrenches  and  strains.  It  is  important  to 
recollect  that,  although  the  cord  itself  ends  at  the 
spot  indicated,  the  dura  mater,  the  arachnoid, 
and  the  collection  of  cerebro-spinal  fluid  extend 
as  far  as  the  third  piece  of  the  sacrum  (Fig.  151). 
Injuries  inflicted,  therefore,  upon  the  spine  as 
low  down  as  this  latter  point  may  cause  death  by 
inducing  inflammation  of  the  meninges.  The  cord 
in  the  dorsal  region  measures  about  10  mm.  from 
side  to  side,  and  8  mm.  in  the  antero-posterior 
direction.  The  cervical  enlargement  is  largest 
659 


660 


THE  SPINE  AND  SPINAL  GORD      [CHAP. 


opposite  the  fifth  or  sixth  cervical  vertebra,  where 
it  measures  about  13  mm.  from  side  to  side. 
The  greatest  part  of  the  lumbar  enlargement  is 
opposite  the  twelfth  dorsal  vertebra,  where  its 
lateral  measurement  is  about  12  mm. 


Fig.   150. — Section   through   spinal   cord,    membranes,  and 
spinal  canal. 

a.r.,  At  origin  of  anterior  root ;  p.r.,  at  origin  of  posterior  root ;  s.p., 
septum  posticum  ;  p.m.,  pia  mater ;  l.d.,  ligamentum  denticu- 
latum.  The  arachnoid  (arach.),  dura  mater  (dura  ni.),  and  sub- 
arachnoid  space  are  shown. 

The  spinal  dura,  mater  is  a  strong  and  sub- 
stantial membrane,  and  between  it  and  the  walla 
of  the  vertebral  canal  a  considerable  space  exists, 
occupied  by  loose  areolar  tissue  and  a  plexus  of 
veins  (Fig.  150).  It  is  tough,  and  may  remain 
undamaged  when  the  cord  is  completely  severed 
by  a  crushing  force.  It  will  be  readily  understood 
that  injury  and  inflammation  of  the  meninges,  as 
results  of  lesions  applied  to  the  spine,  are  much 
less  frequent  than  are  like  complications  after 


xxvm]  SPINAL  DUKA  MATER  661 

injuries  to  the  skull.  The  looseness  of  the  spinal 
dura  mater,  its  freedom  from  any  but  slight  and 
occasional  attachments  to  the  bone,  and  the  space 
around  it  in  which  effusions  can  extend  with  little 
possibility  of  becoming  limited,  will  explain  the 
rarity  in  the  spine  of  those  complications  which 
follow  upon  depressed  bone  and  extravasations  of 
pus  and  blood  in  connexion  with  the  dura  mater 
within  the  skull.  The  plexus  of  thin-walled  veins 
that  occupies  the  interval  between  the  theca  and 
the  bones  may  prove  a  source  of  extensive  haemor- 
rhage in  cases  of  injury  to  the  column.  The  blood 
so  poured  out  tends  to  gravitate  to  the  lowest  part 
of  the  canal,  and  when  sufficient  in  quantity 
may  produce  pressure  effects  upon  the  medulla 
spinalis. 

Over  the  arches  at  the  posterior  aspect  of  the 
vertebrae  is  situate  a  plexus  of  vessels  (the  dorsi- 
s  pi  rial  veins)  that  receives  blood  from  the  muscles 
and  integuments  of  the  back.  These  vessels  com- 
municate through  the  ligamenta  subflava  with  the 
venous  plexuses  within  the  spinal  canal,  and  by 
means  of  this  communication  inflammation  from 
without  may  be  conducted  to  the  theca  of  the 
cord.  Thus,  spinal  meningitis  has  followed  upon 
deep  bedsores,  and  upon  suppurative  affections 
situated  in  the  immediate  vicinity  of  the  spinal 
laminae. 

Within  the  dura  mater  are  two  spaces,  the 
subdural  and  the  subarachnoid,  as  in  the  skull 
(see,  p.  37).  The  arachnoid  is  closely  applied 
to  the  ^  dura  mater,  the  subdural  being  merely  a 
potential  space,  while  the  subarachnoid  is  exten- 
sive (Figs.  150  and  151),  and  occupied  by  cerebro- 
spinal  fluid  which  surrounds  the  cord,  and  is 
continuous  with  the  great  subarachnoid  spaces 
at  the  base  of  the  brain  (Fig.  10,  p.  39).  By 
means  of  this  open  communication  inflammatory 
affections  may  readily  spread  from  the  cord  to 
the  brain.  Into  these  spaces  blood  may  be  ex- 
travasated  in  cases  of  injury.  Instances  have 
been  recorded  where  the  theca  has  been  opened 


662 


THE  SPINE  AND  SPINAL  CORD      [CHAP. 


by  a  wound,  and  the  cerebro-spinal  fluid  has 
escaped  in  large  quantities  The  fluid  normally 
contains  0*05  per  cent,  of  albumin,  but  if  the  mem- 
branes are  inflamed  the  percentage  may  be  double 
that  amount.  In  certain  conditions  the  pressure 


OflUi/lEDULLARlS 


DURA  /IATER. 

5uBARACrtflOID  SPACE 

FILUM  TERAH/IALE 

LlCAttEAITUM  SUBFLAV. 


/NERVE  ROOTS 


Fig.  151. — Vertical  section  of  the  lower  part  of  the  spina 
column  to  show  the  position  and  extent  of  the  sub 
arachnoid  space. 

The  arrow  shows  the  point  for  lumbar  puncture. 

of  the  fluid  may  rise  to  such  an  extent  as  tc 
cause  death.  In  normal  conditions  the  fluid  is 
absorbed  at  any  pressure  above  that  of  the  sur- 
rounding veins  (Hill).  In  the  recumbent  posture 
the  pressure  should  support  a  column  of  water 


xxvm]  LUMBAR   PUNCTURE  663 

2  inches  high;  in  the  upright  posture,  6^8  inches. 
With  each  muscular  effort,  as  in  coughing  or  in 
sudden  expiratory  exertion,  the  intraspinal  veins 
dilate  and  the  cerebro-spinal  pressure  rises.  In 
disease  it  may  rise  to  ten  times  the  normal 
amount.  The  pressure  may '  be  relieved  by  a 
lumbar  puncture,  made  by  thrusting  a  needle 
8-10  cm.  long  into  the  subarachnoid  space  in  the 
lumbar  region  of  the  spine.  A  point  is  selected 
between  the  third  and  fourth  lumbar  spines, 
exactly  in  the  middle  line,  because  here  the 
interlaminar  spaces  are  widest  and  the  danger 
of  wounding  blood-vessels  and  nerve-roots  is  less 
than  if  a  lateral  point  were  selected.  The  fourth 
lumbar  spine  may  be  readily  identified  because  it 
lies  on  a  level  with  the  highest  points  of  the 
iliac  crests  (Fig.  152).  The  interlaminar  space  is 
much  increased  when  the  spine  is  bent  forwards.; 
hence  the  patient  is  placed  bent  and  reclining 
on  the  side,  or  in  a  sitting  posture  and  leaning 
forwards.  The  point  of  the  trocar  is  pushed  in 
the  direction  of  the  umbilicus  (Flack).  The  needle 
perforates  the  ligamentum  subflavum  between 
the  laminae.  Convulsions  follow  if  the  pressure 
be  reduced  much  below  the  normal.  At  this 
level  the  cord  cannot  be  injured,  but  the  needle 
may  pierce  one  of  the  lower  nerve-roots,  causing 
twitching  in  muscles  of  the  lower  extremity. 

The  injection  of  stovaine  or  allied  sub- 
stances into  the  subarachnoid  space  to  produce 
spinal  analgesia  is  performed  at  the  same  point 
as  lumbar  puncture.  The  injection  should  not 
be  made  until  the  cerebro-spinal  fluid  escapes 
freely  from  the  cannula  when  the  trocar  is  with- 
drawn^ for  unless  this  occurs  the  cannula  is  not 
yet  within  the  subarachnoid  space.  Usually 
20-30  cm.  of  fluid  is  withdrawn,  and  replaced 
bv  an  equal  amount  of  fluid  or  serum.  In  cases 
of  cerebral  compression  there  is  a,  risk,  when 
fluid  is  suddenly  withdrawn,  of  the  medulla 
and  cerebellum  being  forced  like  a  cork  into  the 
foramen  magnum,  becoming  thus  compressed  and 


664 


THE  SPINE  AND  SPINAL  CORD      [CHAP. 


anaemic,  with  sudden  death  as  a  result.  Mr.  Barker 
has  pointed  out  that  the  lowest  part  of  the  sub- 
arachnoid  space  when  the  body  is  supine  is  that 


SACffAL   CANAL. 


Fig.  152. — Diagram  of  the  lumbar  interlaminar  spaces, 
showing  the  position  of  the  fourth  lumbar  spine. 

situated  in  the  mid-dorsal  region,  and  that  there- 
fore a  fluid  which  is  of  greater  specific  gravity 
than  that  of  the  cerebro-spinal  fluid  (1007)  will 


xxvm]         WOUNDS   OF  SPINAL  CORD 


665 


tend,  if  injected  in  the  lumbar  region,  to  gravi- 
tate to  that  part.  By  raising  and  lowering  the 
patient's  shoulders  the  rate  of  diffusion  of  the 
anaesthetic  can  be  regulated  to  a  considerable 
degree.  Injections  have  also  been  made  in  the 
upper  dorsal  and  cervical  regions  through  the 
interlaminar  spaces,  the  spine  being  bent  to 
extend  these  to  their  greatest  width. 

The  position  of  the  cord  is  such  that  it  is  not 
readily  reached  in  incised  and  punctured  wounds. 
The  only  spots  at  which  it  is  easy  of  access  are  the 
intervals  between  the  atlas  and  occiput  and  the 


SPINAL  CORD 
—  DURA  MATER 
ARACHNOID 
SUBARACH.  SPACE 
FILUM  TERMINALE 


Fig.   153. — Diagrammatic  vertical  section  of  the  conus 
medullaris,  filum  terminate,  and  spinal  membranes. 

atlas  and  axis.  Many  cases  have  been  recorded  of 
fatal  wound  o>f  the  cord  in  these  positions.  Lower 
down  in  the  column  the  medulla  spinalis  may  be 
reached  if  the  wound  have  a  certain  direction. 
Thus  a  case  is  reported  where  a  pointed  body 
entered  the  canal  between  the  ninth  and  tenth 
dorsal  vertebrae,  having  been  introduced  from 
below  upwards. 

Several  examples  of  damage  to  the  cord  by 
sword  or  bayonet  wounds  have  been  put  on  record, 
but  in  most  of  these  instances  the  wound  was 
associated  with  some  fracture  of  the  protecting 


666         THE   SPINE  AND   SPINAL  CORD      [CHAP. 

bone.  Modern  bullets,  with  their  high  velocities, 
cause  great  damage  when  they  enter  the  spinal 
canal,  not  only  to  the  structures  lying  in  their 
immediate  track,  but  also  to  remote  parts.  Such 
bullets,  when  they  enter  the  cerebro-spinal  cavity 
—a  closed  cavity — exercise  an  explosive  effect, 
leading  to  haemorrhages  and  bruising  of  all  parts 
within  the  enclosed  space. 

The  pia  mater  forms  a  strengthening  sheath 
for  the  cord.  On  it  the  arteries  ramify  before 
entering  to  supply  its  substance.  The  verte- 
bral, intercostal,  lumbar,  ilio-lumbar,  and  lateral 
sacral  arteries  send  twigs  along  the  nerve-roots 
to  the  cord. 

Concussion  of  the  cord. — After  certain  in- 
juries to  the  back  a  train  of  symptoms,  usually 
of  a  severe  and  complicated  character,  has  been 
described  and  assigned  to  a  concussion  or  shaking 
of  the  spinal  cord. 

In  these  injuries  it  is  assumed  that,  as  a  result 
of  a  sudden  shock  transmitted  to  it,  the  cord 
becomes  the  seat  of  minute  haemorrhages,  which 
lead  to  a  more  or  less  severe  disturbance  of  its 
function;  and  the  condition  has  been  compared 
to  concussion  of  the  brain,  although  it  must 
be  admitted  that  the  symptoms  often  accredited 
to  concussion  of  the  cord  have  a  character  more 
complex  than  those  seen  in  like  lesions  of  the 
more  complex  organ. 

The  spinal  cord  is  swung  or  suspended  in 
its  bony  canal,  and  is  separated  from  fhe  walls 
of  that  canal  on  all  sides  by  a  considerable 
interval.  It  is,  indeed,  only  held  in  position  by 
the  nerve-trunks  that  pass  out  from  it  through 
the  inter  vertebral  foramina,  and  by  its  con- 
nexions with  the  theca.  Above,  it  is  connected 
with  that  part  of  the  brain  that  lies  upon  the 
largest  imtracranial  collection  of  cerebro-spinal 
fluid  (p.  38),  and  it  would  appear  that  the 
mpst^  violent  movements  possible  of  the  brain 
within  the  skull  could  be  but  very  feebly  communi- 
cated to  the  spinal  cord.  The  cord,  moreover,. 


xxvm]          CRUSHING  OF  THE  CORD  667 

within  its  theca,  is  surrounded  on  all  sides  by  a 
space  occupied  by  cerebro-spinal  fluid.  It  is  diffi- 
cult to  understand,  therefore,  how  a  structure  so 
protected  can  be  so  violently  disturbed  by  a  shock 
received  upon  the  body  as  to  undergo  a  grave  and 
progressive  loss  of  function.  The  cord  is,  indeed, 
somewhat  in  the  position  of  a  caterpillar  sus- 
pended by  a  thread  in  a  phial  of  water.  _  It  would 
probably  be  difficult  permanently  to  disturb  the 
internal  economy  of  such  an  insect  (even  if  it  had 
a  structure  as  elaborate  as  the  cord)  by  other  than 
violence  that  would  be  comparatively  excessive. 

Contusion  and  crushing:  of  the  cord.— As 
has  already  ^  been  observed,  the^  gravity  of  frac- 
tures and  dislocations  of  the  spine  depends  upon 
the  extent  of  the  damage  received  by  the  cord.  In 
these  accidents  it  is  very  usual  for  some  part 
of  the  injured  vertebra  to  be  projected  into  the 
spinal  canal,  so  as  to  press  upon  or  actually  crush 
the  delicate  nerve-centre  that  it  contains. 

It  is  needless  to  observe  that  the  cord  is  ex- 
tremely soft,  and  thus  it  happens  that  it  may  be 
entirely  broken  up  by  violence  without  the  mem- 
branes being  perceptibly  damaged.  Indeed,  in 
fracture-dislocations  it  is  unusual  for  the  theca 
to  be  torn,  and  it  is  possible  for  the  cord  to  be 
quite  crushed  at  some  one  spot  without  the  corre- 
sponding membranes  being  in  any  way  lacerated. 
The  amount  of  damage  inflicted  upon  the  cord 
will  vary,  of  course,  with  the  magnitude  of  the 
accident;  but,  other  things  being  equal,  it  will 
be  found  to  be  more  severely  injured  in  fracture- 
dislocations  of  the  cervical  and  dorsal  segments 
than  in  like  lesions  in  the  lumbar  spine.  In  the 
atlanto-axial  region  the  amount  of  displacement 
that  follows  upon  luxation  of  the  two  bones  from 
one  another  is  such  that  the  cord  is,  as  a  rule, 
severely  crushed,  and  death  ensues  instantaneously, 
as  is  seen  in  cases  of  death  by  hanging.  In  the 
cervical  and  upper  dorsal  segments  of  the  column 
the  vertebral  bodies  are  small,  the  spine  is  mobile, 
the  fractures  met  with  in  these  parts  are  usually 


668  THE  SPINE  AND  SPINAL  OORD      [CHAP. 

due  to  indirect  violence,  and  are  associated  with 
much  displacement.  In  the  lower  dorsal  region, 
again,  the  greater  rigidity  of  the  spine  renders 
any  displacement,  when  it  does  occur,  likely  to  be 
considerable.  In  the  lumbar  region,  on  the  other 
hand,  it  must  be  noted  that  the  cord  only  ex- 
tends to  the  lower  border  of  the  first  vertebra.  The 
bodies  of  the  vertebrae,  also,  in  this  district,  are 
very  large  and  cancellous,  and  can  undergo  a 
severe  amount  of  crushing  without  a  correspond- 
ing degree  of  displacement  being  produced.  The 
part,  too,  is  well  protected  by  the  large  inter- 
vertebral  discs,  and  by  the  immense  masses  of 
muscle  that  surround  the  spine  in  the  loins.  Such 
portion  of  the  spinal  cord  as  extends  into  the 
lumbar  region  is  protected  also  by  the  many  cords 
of  the  cauda  equina,  which,  by  their  looseness 
and  comparative  toughness,  tend  to  minimize  the 
effects  of  violence. 

The  degree  of  displacement  of  bone  required  to 
produce  pressure  effects  upon  the  cord  is  often 
greater  than  would  be  supposed.  At  post-mortem 
examinations  portions  of  injured  vertebrae  have 
been  found  encroaching  upon  the  spinal  canal  to 
a  considerable  extent  in  cases  where  no  evidences 
of  damage  to  the  cord  existed  during  life.  Dr. 
J.  W.  Ogle  reports  the  case  of  a  man  who,  after 
an  injury  to  the  neck  from  a  fall,  presented  no 
spinal  symptoms  until  three  days  had  elapsed. 
He  ultimately  became  paralysed,  and  died  thirty- 
two  days  after  the  accident.  The  autopsy  revealed  a 
dislocation  forwards  of  the  sixth  cervical  vertebra, 
of  such  an  extent  that  the  body  below  projected 
at  least  i  an  inch  into  the  spinal  canal. 

The  remarkable  manner  in  which  the  cord  will 
accommodate  itself  to  a  slowly  progressing  pres- 
sure is  often  well  seen  in  the  results  of  chronic 
bone-disease  in  the  column. 

The  symptoms  due  to  injury  to  the  cord  and  to 
the  nerves  contained  in  the  spinal  canal  will  ob- 
viously depend  upon  the  situation  and  extent  of 
the  lesion.  The  diagnosis  of  the  situation  of  the 


xxvm]  SPINAL  NERVES  669 

lesion  is  complicated  by  the  relation  the  nerves 
bear  to  the  various  vertebrae,  and  by  the  fact  that 
the  majority  of  the  great  trunks  arise  from  the 
cord  at  a  spot  above  the  point  at  which  they 
issue  from  the  vertebral  canal.  The  two  highest 
nerves,  the  first  and  second  cervical,  pursue  an 
almost  horizontal  course  in  their  passage  from  the 
cord  to  their  points  of  exit  from  the  canal.  The 
remaining  nerves  take  a  more  and  more  oblique 
direction,  until  at  last  the  lowest  nerve-trunks  run 
nearly  vertically  downwards  as  they  pass  to  their 
respective  intervertebral  foramina. 

Points  of  exit  of  nerves  from  the  vertebral 
canal.— The  first  cervical  nerve  leaves  the  canal 
above  the  first  cervical  vertebra.  The  remaining 
cervical  trunks  escape  also  above  the  vertebrae 
after  which  they  are  named,  the  eighth  cervical 
nerve  leaving  the  canal  between  the  last  cervical 
and  the  first  dorsal  vertebrae.  The  dorsal,  lumbar, 
and  sacral  nerves  have  their  points  of  exit  below 
the  vertebrae  after  which  they  are  named.  Thus, 
the  first  dorsal  nerve  will  pass  through  the 
foramen  between  the  first  and  second  dorsal 
vertebrae,  and  BO  on. 

Points  of  Origin  from  the  Cord 
The  first  cervical  nerve  arises  from  the  cord  opposite  the  interval 

between  the  atias  and  occiput. 
The  second  and  third  cervical  nerves  arise  from  the  cord  opposite 

the  axis. 
The  fourth,  fifth,  sixth,  seventh,  and  eighth  cervical  nerves  arise 

from  the  cord  opposite  the  third,  fourth,   fifth,  sixth,  and 

seventh  vertebrae  respectively. 
The  first  four  dorsal  nerves  arise  from  the  cord  opposite  the  discs 

Mow  the   seventh  cervical  and  the  first,  second,  and  third 

dorsal  vertebrae  respectively. 
The  fifth  and  sixth  dorsal  nerves   arise  from  the  cord  opposite 

the  lower  borders  of  the  fourth  and  fifth  vertebrae. 
The  remaining   six   dorsal  nerves  arise  from  the   cord   opposite 

the  bodies  of  the  sixth,   seventh,  eighth,  ninth,  tenth,  and 

eleventh  vertebrae. 
The  first  three  lumbar  nerves  arise  from  the  cord  opposite  the 

twelfth  dorsal  vertebra. 
The  fourth  lumbar  nerve  arises  from  the  cord  opposite  the  disc 

between  the  twelfth  dorsal  and  first  lumbar  vertebrae. 


670  THE  SPINE  AND  SPINAL  CORD      [CHAP. 

The  last  lumbar  nerve,  together  with  the  sacral  and  coccygeal 
nerves,  arises  from  the  cord  opposite  the  first  lumbar 
vertebra. 

It  will  be  seen,  therefore,  that  in  noting 
the  symptoms  due  to  crushing  of  the  entire  nerve 
contents  of  the  vertebral  canal  at  a  certain  spot, 
account  must  be  taken,  not  only  of  the  effects 
of  damaging  the  medulla  at  that  point,  but  also  of 
the  result  of  lacerating  nerve-trunks  that  may 
issue  there,  although  their  origins  are  above  the 
seat  of  lesion.  The  cord  is  also  very  often  only 
damaged  in  part,  or  it  may  entirely  escape,  while 
one  or  more  nerves  are  crushed  by  the  fractured 
vertebrae  or  by  fragments  of  bone  separated  by 
the  lesion. 

In  fracture-dislocations  the  upper  vertebral 
body,  as  already  stated,  usually  glides  forward, 
with  the  result  that  the  anterior  and  antero- 
lateral  parts  of  the  cord  are  brought  into  violent 
contact  with  the  projecting  border  of  the  ver- 
tebra below  the  seat  of  lesion. 

It  is  in  these  parts  of  the  cord  that  the  main 
motor  tracts  run,  and  thus  it  happens  that  motion 
is  more  often  lost  in  the  parts  below  the  site  of 
the  injury  than  is  sensation.  If  there  be  partial 
motor  and  sensory  paralysis,  the  disturbance  of 
the  former  function  is  likely  to  be  in  excess  off 
that  of  the  latter.  In  no  case,  indeed,  does  there 
appear  to  have  been  a  loss  of  sensation  without,  at 
the  same  time,  some  disturbance  in  the  powers  of 
movement.  If  the  grey  matter  of  the  cord  be  not 
severely  damaged,  reflex  movements  appertaining 
to  that  segment  of  the  cord  can  usually  be  induced 
in  the  paralysed  parts  by  proper  stimulation.  If 
those  reflex  movements  be  lost,  it  may  be  inferred 
that  the  grey  matter  is  broken  up,  and  that  the 
entire  spinal  medulla  has  been  crushed  at  the  seat! 
of  lesion. 

The  higher  up  the  fracture  in  the  column  the 
greater  is  the  tendency  for  the  function  of  respira- 
tion to  be  interfered  with.  If  the  lesion  be  at  the 
upper  end  of  the  dorsal  spine,  then  not  only  will 


xx vin]      THE  CORD   AND   MICTURITION          671 

all  the  abdominal  muscles  be  paralysed,  but  also 
all  the  intertostals.  A  fracture  associated  with 
injury  to  the  cord,  when  above  the  fourth  cer- 
vical vertebra,  is,  as  a  rule,  instantaneously  fatal. 
The  phrenic  nerve  comes  off  mainly  from  the 
fourth  cervical  nerve,  receiving  contributions  also 
from  the  third  and  fifth.  The  fourth  nerve  issues 
just  above  the  fourth  cervical  vertebra.  If  the 
cord  be  damaged  immediately  below  this  spot, 
the  patient  can  breathe  only  by  means  of  the 
diaphragm;  and  if  the  lesion  be  so  high  as  to 
destroy  the  main  contribution  to  the  phrenic, 
respiration  of  any  kind  becomes  impossible. 

Certain  disturbances  of  micturition  are  fre- 
quent in  cases  of  injury  to  the  cord.  The  re- 
flex centre  for  this  act  is  lodged  in  the  lumbar 
enlargement.  The  irritation  of  the  vesical  walls, 
produced  by  the  increasing  distension  of  the 
bladder,  provides  the  needful  sensory  impulse. 
This  impulse  is  reflected  to  the  nerves  controlling 
the  bladder  muscles,  and  especially  to  the  detrusor 
urinse,  and  by  their  contraction  the  organ  is 
emptied  (p.  488).  The  action,  however,  can  be 
inhibited  by  voluntary  impulses  passing  down 
from  the  brain  to  the  lumbar  centre,  and  the 
tendency  to  a  frequent  discharge  of  urine  is  re- 
sisted by  contraction  of  the  sphincter.  When, 
therefore,  any  part  of  the  cord  between  the 
lumbar  centre  and  the  brain  is  damaged,  inhi- 
bition can  have  no  effect.  Immediately  after 
the^  accident  the  temporary  suspension  of  reflex 
actions  from  shock  produces  some  retention  of 
urine,  and  after  that  the  bladder  empties  itself  at 
frequent  intervals,  the  patient  being  unconscious 
of  the  act  and  unable  to  influence  it. 

If  the  centre  itself  be  damaged  in  the  lumbar 
cord,  the  bladder  itself  may  attain  a  power  of 
periodical  action,  over  which,  of  course,  the 
patient  has  no  control;  and  a  like  result  will 
follow  if  the  nerve  connexions  between  the  cord 
and  bladder  below  <  the  spinal  centre  have  been 
destroyed.  The  principal  nerves  connecting  the 


672  THE  SPINE  AND  SPINAL  GORD      [CHAP. 

medulla  spinalis  with  the  bladder  are  the  third 
and  fourth  sacral. 

The  act  of  defalcation  also  is  apt  to  be  dis- 
turbed in  a  like  manner.  Here  there  is,  as  in  the 
previous  case,  a  reflex  centre  in  the  lumbar  en- 
largement, with  motor  and  sensory  nerves  connect- 
ing it  below  with  the  rectum  and  its  muscles; 
and  also  between  this  centre  and  the  brain  are 
tracts,  but  little  known,  along  which  inhibitory 
actions  can  extend.  In  lower  animals  the  brain 
has  but  an  imperfect  control  of  these  reflex 
centres,  but  even  in  them  this  control  can  be 
established  by  education. 

When  the  centre  itself  is  damaged,  or  the  con- 
nexion severed  that  unites  it  with  the  viscus,  the 
patient  will  suffer  from  incontinence  of  faeces  and 
will  be  unable  in  any  way  to  control  the  act. 
When  the  cord  is  damaged  at  any  spot  between 
the  reflex  centre  and  the  brain,  then  the  act  of 
defsecation  will  be  performed  at  regular  intervals, 
without  either  the  patient  being  conscious  of  the 
act  or  being  capable  of  inhibiting  it. 

In  some  injuries  to  the  cervical  cord  the 
patient  has  suffered  from  severe  vomiting  for  some 
time  after  the  accident,  or  has  exhibited  a  remark- 
able alteration  in  the  action  of  his  heart.  Mr. 
Erichsen,  for  example,  reports  the  case  of  a  man 
who,  after  a  severe  blow  upon  the  cervical  spine, 
continued  to  vomit  daily  for  several  months.  In 
the  other  category,  instances  have  been  recorded 
where  the  pulse  has  sunk  as  low  as  48,  or  even 
36  or  20,  after  lesions  to  the  column  in  the  neck. 

It  should  be  remembered  that  the  accessory 
trunk  has  origin  from  the  cord  as  low  down  as 
the  sixth  or  seventh  cervical  nerves.  Some  details 
concerning  the  position  of  centres  in  the  spinal 
cord,  connected  with  areas  of  ^  skin,  groups  of 
muscles,  and  viscera,  have  been  given  already  when 
dealing  with  the  nerve  supplies  of  the  abdomen 
and  extremities  (see  pp.  361  and  646). 

Spina  bifida.  —  This  term  refers  to  certain 
congenital  malformations  of  the  vertebral  canal 


xxviu]  SPINA  BIFIDA  673 

associated  with  the  protrusion  of  some  of  its 
contents  in  the  form  of  a  fluid  tumour.  The 
malformation  usually  consists  in  an  absence  of 
the  neural  arches  and  spines  of  certain  of  the 
vertebrae,  and  the  tumour  therefore  projects 
posteriorly.  Spina  bifida  is  most  common  in 
the  lumbo-sacral  region,  the  neural  arches  of  the 
last  lumbar  and  of  all  the  sacral  vertebrae  being 
absent.  In  development  the  neural  arches  close 
first  in  the  dorsal  and  last  in  the  lumbo-sacral 
region.  Next  in  frequency  it  is  found  limited  to 
the  sacral  region.  It  is  rare  elsewhere.  (1)  The 
membranes  may  protrude  alone  (spinal  meningo- 
cele).  (2)  The  membranes  may  protrude  together 
with  the  spinal  cord  and  its  nerves  (meningo- 
myelocele).  (3)  The  membranes  may  protrude 
with  the  cord,  the  central  canal  of  which  is 
dilated  so  as  to  form  a  sac-like  cavity  (syringo- 
myelocele). 

The  meningo-myelocele  is  the  most  common 
form.  The  first-named  variety  is  rare,  the  last- 
named  very  rare.  The  fluid  which  distends  the 
sac  is  cerebro-spinal  fluid,  and  is  continuous  with 
that  system  of  the  cord  and  brain.  When  com- 
pressed, the  fluid  is  forced  into  the  subarach- 
noid  spaces  at  the  base  of  the  brain,  which  is 
forced  upwards  against  the  anterior  fontanelle, 
where  its  impact  may  be  felt.  The  tumour  bo- 
comes  enlarged  and  tense  when  the  child  cries. 
The  distension  of  the  cerebral  and  spinal  veins 
forces  the  fluid  in  the  direction  of  least  resist- 
ance. The  wall  of  the  sac  is  formed  by  (1)  the 
membranes,  (2)  the  skin,  and  (3)  an  intermediate 
membrane  corresponding  to  the  flattened-out,  un- 
closed neural  lamina  which  represents  the  lumbar 
part  of  the  spinal  cord  and  to  which  the  nerves 
are  attached.  Hence,  with  spina  bifida  there  is 
usually  a  greater  or  less  degree  of  paralysis  and 
anaesthesia,  with  malformation  of  the  lower  limbs 
and  perineum. 

The  defect  is  produced  at  an  extremely  early 
stage  of  development,  and  hence  part  of  the  cord 
w 


674  THE  SPINE  AND  SPINAL  GORD 

or  of  the  nerves  in  the  region  of  the  tumour 
may  be  absent  or  defectively  developed.  In 
some  cases  the  nerve  affection  takes  the  form 
of  club-foot  of  a  severe  grade.  In  other  instances 
there  is  more  or  less  complete  paralysis  of  the 
lower  limbs,  bladder,  and  rectum. 

Operations  upon  the  cord. — The  late  Sir 
Victor  Horsley  and  others  have  cut  down  upon  the 
spine  and  removed  a  tumour  from  the  spinal  cord 
with  perfect  success,  and  with  relief  to  the  symp- 
toms from  which  the  patient  was  suffering.  The 
spinal  canal  has  also  been  exposed  in  certain  cases 
where  callus  in  an  old  fracture  of  the  spine  was 
pressing  upon  the  cord,  or  where  a  small  osseous 
growth  was  encroaching  on  the  canal. 


INDEX 


bees  en  bissac,  612 

—  en  bouton  de  chemise,  612 
bdomen,  347 

—  abscess  of,  382 

-  blood-vessels  of,  358,  460 

—  blows  on,  352 

—  congenital  deformities  of, 

364 

—  connective  tissue  of,  357 

—  fascia  of,  351,  381 

—  lumbar  region  of.  384 

—  lymphatics  of,  358 

—  muscles  of,  355,  395 

—  nerves  of,  359 

—  parietes  of,  anterior,  351 

—  posterior,  381 

—  referred  pains  in,  361 

—  skin  of,  350 

—  surface  anatomy  of,  347 

—  tension  or  pressure  with- 

in, 373 

-  viscera  of,  386,  432 

—  nerve  supply  of,  458 

support  of,  395 

surface  markings  of, 

392 

—  wounds  of,  357 
dominal  aorta,  350 

—  belt,"  351 

—  connective  tissue  and  ab- 

scesses, 357 

—  rings,  366,  369 
scess.  alveolar,  148 

-  axillary,  254 

—  cerebellar,  trephining  for, 

14 
in     middle-ear     dis- 


—  cerebral,    trephining   for, 

12 

—  cervical,  182 

-  gluteal,  528 

—  hepatic,  436 

-  iliac,  357,  382 

—  in  antrum,   120 

—  in  femoral  triangle,  535 

-  in  hip-joint,  542 


675 


Abscess  in  scalp,  6 

—  in  temporal  fossa,  8 

—  intercostal,  218 

—  ischio-rectal,  477,  478 

—  lumbar,  385 

—  mediastinal,  215,  232 

—  of  abdominal  parietes,  382 

—  of  Bartholin's   gland,   507 

—  of  inferior  temporal  con- 

volution, 48 

—  orbital,  59 

palmar,  320 

—  parotid,  135 
pelvic,  542 

— -  perinephritic,  448 
plantar,  612 

—  popliteal,  574 

—  postpharyngeal,   135,   168 

—  prostatic,  493 

—  psoas,  384,  536 

—  renal,  448 

—  retropharyngeal,  115 

—  retropubic,  485 
— -  sacro-iliac,  468 

—  thecal,  324 

—  typhlitic,  418 
Accessory  sinuses,  113 
Acetabulum,  542 

fractures  of,  468 

"  Aching  legs,"  600 
Achondroplasia,  19 
Acne  hypertrophica,  103 
Acromegaly,  42 
Acromio-clavicular  joint,   236, 

248 
dislocations  of,  249 

movements  of,  248 

Acromion  process,  236 

fracture  of,   251 

Acromio-thoracic    artery     238, 

240,  253 

Adductor  longus   muscle,   534 
537 

magnus  tubercle,  569 

Adenoids,  167 

Adrenal   (see   Suprarenal) 
Air  in  stomach,  402 


676 


INDEX 


Air  in  veins,  204,  257 
Air-passages,     foreign     bodies 

in,  195 

Air-sac  in  neck,  211 
Alcohol,    injection    of    nerves 

with,  127,  128,  532 
"  Alderman's  nerve,"  90 
Alimentary    tract,     antiperis- 
talsis  in,  398 

—  nerve  control  of,  398 

—  peristalsis  in,  398 

—  rate  of    progress   of 

contents  of,  422 

sphincteric  points  of, 

396 

—  transport      mechan- 

ism of,  396 
Alveolar  abscess,  148 
Ampulla  of  Vater,  438,  443.  444 
Amputation    (see   the  various 

bones  and  joints) 
Anal  canal,  511 

fixation  of,  473 

—  mucous      membrane 

of,  518 
triangle.  475 

—  valves,  518 
Anastomosis,  abdominal,  461 

—  intestinal,  416,  430 
Anastomotica  magna,  572 
Aneurysm,  aortic,  460 

arterio-venous,  61,  538 

axillary.  258 

—  brachial,  289 

—  carotid,  53 

—  femoral,  538 
gluteal,  530 

in  neck,  53.  203 

popliteal,  576,  577 

—  traumatic,      of      orbital 

arteries,  61 
Ankle,  607 

—  bony  points  of,  607 

—  fascia  of,  611 

—  skin  of,  610 

—  sprains  of,  614 

—  subcutaneous    tissue    of, 

610 

—  surface  anatomy  of,  607 

tendons  of,  608 

division  of,  616 

rupture  of,  615 

Ankle-joint,  607.  618 

amputation  at,  637 

disease  of,  619 

dislocations  of,  619 

effusion  into.  618 

'• fractures  about.  620 

-  ligaments  of,  618 


Ankle-joint,  lines  of,  608 

—  movements  of,  618 

—  nerve  supply  of,  619 

—  vessels  of,  609 
Annular    ligament   of    ankl 

612 

—  of  wrist,  321 
Anosmia,  115 

Anterior  crural  nerve,  538.  5 
paralysis  of,  6 

—  nares,  105 

—  superior  spine,  349 
Anticlinal  spine,  225 
Antiperistalsis   in   colon,    3< 

513 
Antrum,  mastoid,  95 

of  Highmore,  119 

Anus,  518 

—  fissures  of,  518 

—  formation  of,  519 

—  imperforate.   519 

—  malformations  of,  519 

—  nerves  of,  521 
Aorta,  abdominal,  350.  460 
Aponeurosis  (sec  Fascia) 
Appendicitis,  417 
Appendicostomy,  430 
Appendix,  416,  418 

-  length  of,  418 

—  lymphatics  of,  420 
— -  mesentery  of,  419 

—  peristalsis  in,  420 

—  position  of,  418 
Aqueduct  of  Fallopius,  94 
Aqueous  humour,  76 
Arachnoid.  37,  661 
Arcuate  tendon,  472 
Arcus  senilis,  66 

Arm,  275 

- —  amputation  of,  282 

—  fascia  of.  276.  277 

—  lymphatics  of,  288 
— •  muscles  of,  341 

—  nerves  of,  276,  335 

—  skin  of,  276 

—  surface  anatomy  of,  27 
Arnold's  nerve,  90 
Arteries     (sec    Axillary,    o 

and  Blood-vessels) 
Arterio-venous  aneurysms, 

538 

Arthrectomy.  594 
Aryteno  -  epiglottidean    fo' 

166,  190 

Arytenoid  cartilage,  188 
Ascaris  lumbricoides,  411 
Ascending  colon,  423 

—  frontal  convolution,  4 

—  motor  convolution,  49 


INDEX 


677 


trending    parietal    convolu- 
tion, 49,  50 

—  pharyngeal   artery,    172 
sterion,  14 

stragalo-scaphoid  joint,  608 
stragalus,  dislocation  of,  624 
—  fracture  of,  634 

—  ossification  of,  635 
tlanto-axial  region  of  spine, 

652,  667 
tlas,  166,  173 
ttic  of  tympanum,  93 
uditory  meatus,  external,  33, 
88 

—  internal,  33 
uerbach's  plexus,  399 
uricle  (see  Ear) 

iricles,    supernumerary,    87, 

211 
uricular  nerve,  135 

—  great,  177 
iriculo-temporal   nerve,   135 
mlsion  of  fingers,  333 
cilia,  239,  253 

-  fasciae  of,  254 

—  lymphatic  glands  of,  255 

—  relations  of,  253 
Lillary  artery,  239,  240 

E—  aneurysm  of,  258 
—  ligature  of,  258 
relations  of,  258 

|-  glands,  206,  221.  239 

—  removal  of,  256 

-  nerves,  240,   260 

-  region,  abscess  of,  254 

-  vessels,  257 

wounds  of,  257 

s,  166 

rgos  veins,  233 

rbadoes  leg,  540 
rtholin's  duct,  151 

-  gland,  507 

—  abscess  of,  507 
sal  ganglia,  48 

ase    of    epicondyles,"   frac- 
ture at,  296 

-  of  skull,  fractures  of,  27 
ulic  vein,  277 

^ion,  33 

I's  muscle,  490 
ont  arm,"  288 
ops  brachii,  275 

-  tendon  in  arm,  265 

—  in  ham,  575 
ipital  fascia,  287 

lfi-  grooves,  238,  275,  276,278 
Jp-duct.    common,    relations 
'iof,  437,  444 


Bile-duct,  rupture  of,  439 
Bismuth-laden    food,    m  o  v  e- 

ments    of,    in    alimentary 

canal,  422 
Bladder.  483 

cystoscopic     examination 

of,  487,  489 

—  development  of,  355 

—  distension  of,  484 

—  "  double,"  489 

—  emptying   and   filling   of, 

483 
- —  extroversion  of,  364 

fasciculated,  488 

female,  490 

foreign  bodies  in,  488,  490 

in  children,  482,  490 

—  in  hernias,  485 

—  male,  483 

—  mucous  membrane  of,  487 

—  muscles  of  fixation  of,  473 

muscular    coats    of,    483, 

486 

nerves  of,  488,  521 

puncture  of,  per  rectum, 

486 

—  relations    of,    to    perito- 

neum, 485 

—  rupture  of,  486 

—  sacculated,  489 

—  sphincter  of,  484 

—  stone  in,  482 

—  trigone  of,  487 

-  X-ray  examination  of.  484 
Blood  tumours  of  scalp,  7 

—  on  pinna,  90 
Blood-vessels  of  abdomen,  350, 
358,  460 

-  of  ankle,  609 

—  of  auditory  meatus,  90 

—  of  axilla,  257 

—  of  breast,  219,  223 

—  of  buttocks,  527,  530 

—  of  cerebellum,  54 

—  of  cerebrum,  36,  52 
of  conjunctiva,  70 

—  of  elbow,  286,  289 

—  of  eyeball,  69 
— -  of  eyelids,  82 

—  of  face,  122,  136 

—  of  femoral   triangle.    533 

—  of  foot,  609,  616 
of  forearm,  302 

—  of  gall-bladder,  437 

-  of  hand,  326 
of  heel,  638 

of  knee.  571.  575 

of  leg,  597,  599 

of  lips,  151 


678 


INDEX 


Blood-vessels  of  mamma,  219, 
223 

of  meninges,  35 

of  nasal  cavities,  113 

.  of  neck,   173,   175,   203 

of  orbit,  61 

of  palate,  hard,  162 

soft,  164 

of  parotid  gland,   136 

of  perineum,  476  (Fig.  105) 

of  pinna,  90 

of  rectum,  514 

—  of  retina,   71 
of  scalp,  8 

—  of  Scarpa's  triangle,  533 
of  spermatic  cord,  505 

—  of  spinal  cord,  666 

of  tongue,  154,  155 

of  tonsil,  171 

—  of  tympanum,  101 
Bones,  nerve  supply  of,  346 
Bony  vault  of  cranium,  17 
Brachial  aponeurosis,  277 

artery,  275,   278,   284,  288, 

289 
abnormalities  of,  279 

plexus,   177,   185,   258,   325 

paralysis  of,  344 

relations  of.  259 

Brachialis  anticus,  278 
Brain,  34 

• areas  of,  motor,  44,  49 

sensory,   50 

basal  ganglia  of,  48 

blood-vessels  of,  52 

—  cisternse  of,  38 

—  concussion  of,  51 

—  convolutions  of  (sec  Con- 

volution) 

cortex  of,  44,  48 

fissures  of,   43,45 

injuries  to,  54 

membranes  of,  34 

—  pulsations  of,  53 

surface  relations  of.  43 

temporal  lobe  of,   43 

Branchial  fistulse,  209 
Brasdor's  operation,  203 
Breaking-point  of  nerves,  531 
Breast  (see  Mamma) 
Bregma,  17 

Broca's  convolution,  47 
Bronchi,     foreign    bodies     in, 

196,  229 
Bronchial    lymphatic    glands, 

201 

Bronchiectasis,  227 
Bronchocele,  196 
Bronchoscope,  229 


Brunner's  glands,  413 
Buccal  cavity,  151 

- —  lymphatic  glands  o 
208 

—  nerve,  128 
Bulla  ethmoidalis,  111 
Bunions,  614 

Bursse  about  elbow-joint,  291 

about  femoral      triangl 

536 

—  about  foot,  612,  614 

about  ham,  578 

—  about  hyoid,  187 

—  about   knee,   573,   578 

—  about   shoulder-joint,   2 

over     great     trochante 

520 

over     ischial     tubercsit 

520 

—  patellar,  573 

—  subacromial,  264 
subpsoal,  536 

Buttocks,  523 
— -  abscess  of,  528 
—  fascia  of,  deep,  528 

subcutaneous,    527 

fold  of,  524 

nerves  of,  527,  530 

skin  of,  527 

—  nerve  supply  of,  5 

subcutaneous    fascia    > 

527 

surface  anatomy  of,  5' 

vessels  of,  527,  530 

Ceecum,  416 

foreign  bodies  in,  418 

hernia  of,  417 

in  intestinal  obstructs 

421 

lymphatics  of,  420 

mobility  of,  417 

movements  in,  418 

opening  of,  430 

—  position  of,  417 
Caesarean  section,  468 
Calcanean  spur,  634 
Calcaneo-cuboid  joint,  608 
Calcaneo-scaphoid       ligamc 

607,  630,  631 

Calcaneus  (see  Os  calcis) 
Calcar  femorale,  550 
Calculi,  biliary,  437,  439 

renal,  456 

—  vesical,  482 
Calyces  of  kidney,  456 
Canal  of  Nuck.  373 

of  Schlemm,  77 

Cancer  en  cuirasse,  221 


INDEX 


679 


Cancer  of  breast,  222 

-  of  pylorus,  444  > 

—  of  rectum,   516 

of  stomach,   235,   407 

—  of  tongue,  159 
Capsule  of  lens,  74,  75 

-  of  shoulder-joint,  264 

-  of  Tenon,  57 
Cardiac  orifice,  399 

-  sphincter,  396 

Varies  of  lumbar  vertebrae,  385 

of  skull,   22 

-  of  spine,  385,  658 

-  of  sternum,  215 

-  of  teeth,  146 
—  sicca,"  99 

Carotid    artery,    52,    173,    175, 
203 

—  aneurysm  of,  203 

—  external,  136 
internal,  95,  168,  171 

ligature  of,    203 

—  sheath  of,   182 

—  tubercle,   173,  204 
larpo-metacarpal    joints,    50, 

329 

larpus   (see  Wrist-joint) 
lartilages,  costal,  216 
iastration,  495,  506 
lataract,  75 

atheterization  of  Eustachian 
tube,  100 

-  of  urethra,   495 
auda  equina,  668 
avernous   sinus,   37 
ephalhaematomata,  7 
ephalic  vein,  284,  287 
'erebellar  abscess,  trephining 

in.  14 

localization,  54 

erebellum,  tumours  in,  54 

veins  of,  54 
erebral    abscess    in    middle 
ear  disease,  48 

—  trephining  for,   32 
artery,  52 
circulation,  52 
localization,  48 
tumour,    pressure    effects 

of,  on  cortex,  50 

—  trephining   for,    15 
erebro-spinal    fluid,    39,    661, 

662 

in  cranial  spaces,  39 

!ervical  abscess,   182 

—  air-cyst,  211 

—  arteries,   177 

—  fasciae,  179 

—  glands,  deep,  206 


Cervical  glands,  deep,  removal 

of,  208 

—  superficial,  206 
—  nerve,  superficial,  177 

part  of  sympathetic  cord, 

injury  to,  205 

region  of   spine.   630 

ribs,  183 

sac,  211 

sinus,  210 

sympathetic,  paralysis  of. 

63 

(see  also  Neck) 

Cervico-dorsal  region  of  spine, 

652 

Cervix  uteri,  508 
Check  ligaments,  58 
Chemosis,  82 
Chest  (see  Thorax) 
Cholecystectomy,  439 
Cholecystenterostomy,  439 
Cholecystotomy,  439 
Chopart's  operation,  639 
Chorda  tympani  nerve,  101 
Choroid,  67 
Choroidal  cleft,  69 
Ciliary  arteries,  69 

nerves,  71 

zone,  70 

Circle  of  Willis,  52 
Circulus  major,  70 

minor,  70 

Circumcision,  499 

Circumflex     artery,     external, 

rupture  of,  564 
internal,    wound    of, 

565 
posterior,  240,  262 

nerve,  240,  262 

—  scapular  artery,  240 
Cirsoid  aneurysm,  9 
Cisternae  of  brain,  38 
Clavicle,  236,  240 

absence  of,  246 

dislocations  of,  248,  249 

excision  of,  242 

—  fracture  of,  242 
movements  of,  247 

ossification  of,  245 

relations  of,  240,   245 

resection  of,  242 

Clavi-pectoral  fascia,  254 
Claw-foot,  633 

Cleft  palate,  160 

"  Clergyman's     sore     throat," 

191 

Cloacal  urethra,  501 
Club-foot,  628 
Coccygodynia,  470 


680 


INDEX 


Coccyx,  470 
Cochin  leg,  540 
Coeliac  axis,  350,  460 
Colectoray,  430 
Colles's  fascia,  479 

fracture,  329 

Coloboma  iridis,  69 
Colon,  422 

—  antiperistalsis  in,  398,  513 

ascending,  423 

—  congenital    m  a  1  f  o  r  m  a- 

tions  of,   431 

descending,  423 

relations  of,  428 

—  diameters  of,   423 

—  diverticula  of,  427 

excision  of,  430 

iliac,  424 

—  operations  on,   428 

—  pelvic,  425 

—  stricture  of,  423 

—  transverse,  424 
relation  of,  to  liver, 

435 
Colotomy,  iliac,  429 

—  inguinal,  429 

—  lumbar,  424 

Commissures  of  prostate,  491 
Common  bile-duct,  437 

—  iliac  artery,  350 

—  peroneal  nerve,  paralysis 

of,  645 
Concussion  of  brain,  51 

—  of  spinal  cord,  666 
Condyles  of  humerus,  297 
Congenital     absence     of     cla- 
vicle, 246 

of  patella,  588 

of  rectum,  427 

deficiency  of  rectum,  427 

deformities    of    abdomen, 

364 

i dermoid  cysts,  153 

dislocation  of  hip,  553 

exomphalos,  364 

. fistulse,  87,  209 

hernia,  354 

malformations    of    anus, 

519 

of  colon,  431 

—  of  rectum,  520 

—  thyroid  cysts,   153 
Conjunctiva,  effects  of  inflam- 
mation of,  83 

nerves  of,  72 

relations  of,  82 

Constrictor  urethrae,  495,  496, 

497 
Contusion  of  brain,  51 


Contusion  of  spinal  cord,  667 
Convolution,    ascending    fron- 

tal,  49 
motor,  49 

—  parietal,  49,  50 

—  Broca's,  47 

—  inferior  frontal,  47 

—  temporal,   48 

—  postcentral,  49,  50 

—  precentral,  49 

—  superior  frontal,  47 
Cooper's  ligament,  378 
Coraco-acroinial  ligament.  23£ 
Coraco-brachialis  muscle,  239 
Coracoid  process,  238 

fracture  of,  251 

Cornea,  64 

—  dimensions  of,  64 
—  nerves  of,  66 

Coronal  suture    17 
Coronary  glands,  404 

—  lymphatics,  404 
Coronoid  process,  fracture  of 

299 

Corpora  cavernosa,  500 
Corpus  spongiosum,  500 

—  striatum,  48 

Cortex,     cerebral,     areas     of 

motor,  49 
—  sensory,  50 
auditory,  51 

—  olfactory,  51 
visual,  51 

"  word-seeing,"   51 

Costo-rectal  point,  right,  394 
Costo-vertebral  ligament,  452 
"  Coup  de  fouet,"  599 
Cowper's  gland,  507 
Coxa  vara  and  valga,  552 
Cranial  bones,  blood  suppl- 
of,  5 

—  necrosis  of,  5 

—  nerves,  61 

—  spaces     containing     cert 

bro-spinal  fluid,  38 
Craniectomy,  30 
Cranio-cleido-dysostosis,  246 
Craniotabes,  18 
Cranium  (see  Skull) 
Cremaster  muscle,  505 
Cremasteric  artery,  505 
Cribriform  plate,  109 
Cricoid  cartilage,  188 
"  Cross  -  legged    progression, 

547 

Crucial  ligaments,  579,  581 
Cruciate  ligament,  612 
Crural  canal,  360 

—  nerve,  anterior,  538,  540 


INDEX 


681 


Crural  nerve,  anterior,  para- 
lysis of,  641 

'  Crutch  paralysis,"  279 

-uboid  bone,  608 

— ossification  of,  635 

Cuneiform   bone,   inner,   607 

Curvatures  of  stomach,  400, 
401 

Jutaneous  nerve,  internal, 
276,  277,  288 

— supply  of  lower  limb, 

641 

—  sensibility,  nerves  of,  338, 

345 

]ut  throat,  185 
"ystic  duct,  437 
'ystocele,  vaginal,  507 
Jystoscopic     examination     of 

bladder,  487,  489 
]ysts  in  mouth,  152,  153 

—  of  scalp,  2 

;)acryops,  84 

)artos  tissue,  352,  502 

)eep  epigastric  artery,  350 

—  sensibility,  129,  338,  346 
>efaecation  in  spinal  injuries, 

672 

Deltoid,  237,  263,  275 
. — •  region,  261 
;- —  tubercle,  236 
,'ental  nerve,  127,  146 
,'ermoid  cysts,  congenital,  153 
Descending  colon,  423 
iaphragm,    relations    of,    to 

liver,  433 
to  stomach,  402 

—  respiratory  movements  of, 

233 

|iaphragmatic  hernia,  379 
igastric  muscle,  175 
jiploic  veins,  10 
iislocation  (see  various  bones 

and  joints) 

ivarication  of  recti,  353 
arsalis  linguae  artery,  171 

—  pedis  artery,  617 

—  scapulae  artery,  240,  253 
:>rso-lumbar  region  of  spine, 

652 

jrsum  ilii,  dislocation  upon, 
554,  556 

—  sellae,  33 

i  Double  bladder,"  489 

'  '• chin,"  178 

buche,  nasal,  108 
I  Drop-wrist,"  344 
jhctus  deferens,  504,  509 
) modenal  sphincter,  396 
W* 


Duodenal  ulcer,  414 
Duodeno-jejunal  fossa,  414 
Duodenum,  413 

diverticula  of,  414 

occlusion  of,  414 

—  suspensory  muscle  of,  413 
Dupuytren's  contraction,  319 

—  fracture,  622 
Dura  mater,  34,  660 

nerves  of,  35 

Dysphonia  clericorum,  191 

Ear,  87 

— -  bleeding    from,    in    frac- 
ture of  base  of  skull,  29 

—  blood  supply  of,  90 
tumours  on,  90 

—  coughing,  90 

—  external,  87 

—  hsematomata  of,  90 

—  inner,  102 

inflammation  of,  102 

—  lymphatic  glands  of,  208 

—  middle,  94 

— -  nerve  supply  of,  90 

—  ossicles  of,  93 

—  "  serous  "  discharge  from, 

29 

—  sneezing,  90 
yawning,  90 

Ectopia  vesicle,  364 
Ectropion,  80 
Ejaculatory  ducts,  497 
Elbow,  283 

epiphyses  about,  334 

fold  of,  283 

fractures  about,  295 

lymphatic  gland  of,  288 

nerves  of,  288,  289,  300 

.  resection  of,  299 

skin  of,  286 

—  surface  anatomy  of,  283 

vessels  of,  286,  289 

Elbow-joint,  289 

•  ankylosis  of.  300 

—  bursae  about,  290 

—  disease  of,  291 

dislocations  of,  293 

—  ligaments  of,  290 

—  sprains  of,  291,  295 
Elephantiasis    of    lower    limb, 

540 

of  scrotum,  502 

Eminentia  articularis,  132 
Emissary  veins  of  skull,  9 
Emphysema,  226 
Encephalocele,  19,  105 
Encysted  hernia,  372 

hydrocele  of  cord,  372 


682 


INDEX 


Enterectomy,  416 

Enterocele,  vaginal,  507 

Enterotomy,  415 

Entropion,  80 

Epiblastic  mammary  ridge, 
223 

Epicondyles  of  humerus,  frac- 
tures at,  296 

Epicritic  sensibility,  129,  338 

Epididymis,  504 

nerve  supply  of,  504 

Epiglottis,  wounds  of,  186 
Epiphora,  84 

Epiphyses  of  femur,  547,  593 

separation  of,  552 

of  humerus,  separation  of, 

272,  297 

of  olecranon,     separation 

of,  299 

Epiphysis  of  acromion,  separa- 
tion of,  251 

of  clavicle,  separation  of, 

246 

of     coracoid,     separation 
of,  251 

of   femur  in   knock-knee, 

586 

of  humerus,  relations  of, 

261  (Pig.  60) 

of  iliac  crest,  separation 

of,  467 

—  of  radius,  lower,   separa- 
tion of,  331 
upper,  299 

of  tibia,  594 

—  separation  of,  603 
Epipteric  bone,  21 
Epispadias,  500 
Epistaxis,  113 
Erb's  palsy,  259 
Erector  spinae  muscle,  649,  650 
Erysipelas  of  scalp,  10 
Estlander's  operation,  219 
Ethmoidal  cells,  110,  118 
Eustachian   catheter,   passage 

of,  100 

tube,  99 

Eversion  movements,   627 
Excision  (see  special  parts) 
Exomphalos,  congenital,  364 
Exophthalmic  goitre.  199 
Extensor  brevis  digitorum,  609 

communis  digitorum  mus- 

cle, 596 

longus  digitorum  tendon, 

608 
-  hallncis  muscle,   596 

—  tendon,  608 
• pollicis  tendon,  311 


Extensor    secundi    internodii 

311 

Extroversion  of  bladder,  364 
Eyeball,  64 
— —  blood  supply  of,  69 

dangerous  area  of,  74 

nerve  supply  of,  71 

Eyelashes,  81 

Eyelid,  upper,  ptosis  of,  62 
Eyelids,  80 

arteries  of,  82 

nerves  of,  82 

subcutaneous  tissue  of,  8 

sycosis  of,  82 

Face,   121 

—  blood  supply  of,  122 

—  cellular  tissue  of,  121 
— -  development  of,  124 

—  injuries  to,  122 

-  lymphatic  glands  of,  208 

—  nerves  of,  124 

—  parotid  region  of,  133 

—  skin  of,  121 

—  vessels  of,  122 

—  (see  also  Mandible,  Ma? 

ilia,  Mouth) 

Facial    artery,    122,    123,    17: 
172,  175 

—  canal,  94 

—  nerve,  96,  125,  136 
effects  following  sei 

tion  of,  127 

—  neuralgia,  125 
palsy,  85,  137 

-  vein,  123 
Fallopian  tube,  508 
Fallqpius,  aqueduct  of,  94 
Fascia,  abdominal,  351,  381 

—  anal,  472 

— -  axillary,  954 

bicipital,  287 

brachial,  277 

bulbi,  57 

— -  cervical,  179 

—  clavi-pectoral,  254 
gluteal,  527 

iliac,  382 

inguinal,  377 

-  lata,  528,  535,  562 

—  lumborum,  385 

—  obturator,  472 

—  of  ankle,  611 

—  of  arm,  276,  277 
of  buttock,  527 

-  of  Colles,   479 

of  femoral  triangle,  535  ' 

— -  of  foot,  609,  611 

—  of  hand,  313,  319 


INDEX 


683 


Fascia  of  leg,  598 

—  of  scalp,  1,  6 

of  thigh,  562 

palmar,  313,  319 

parotid,   134 

—  pectoral,  254 
pelvic,  471 

perineal,  479 
plantar,  609 

—  popliteal,  574 

—  postnephric,  449 

—  prenephric,  449 

—  Scarpa's,  377 

—  Sibson's,  183 

—  temporal,  7 

—  transversalis,  381 

visceral,  472 

fasciculated  bladder,  488 
'  Fatty  hernia,"  354 

—  tissue  in  scalp,  2 
•'ernoral  artery,  534,  537,  564 

—  canal,  375 

-  diyerticula,   381 
ppiphysis,  593 

hernia,  375 

—  relations  of,  377 

-  nerve,  538,  540 

—  paralysis  of,  641 

—  point,  367 
ring,  375,  534 

-  sheath,  382 

—  triangle,  blood-vessels  of, 

534,  537 
bursa  in,   536 
fascia  of,   535 
lymphatic  glands  of, 

534,  539 

mamma  in,   535 
muscles  of,   536 
— •  nerves  of,  538 
region  of,  533 

—  skin  of,  534 
surface  anatomy  of, 

533 
testicle  in,  535 

-  vein,  phlebitis  of,  538 

-  vessels,  534,  537 

—  aneurysm  of,   538 
moro-sacral  arch,  465 
mur,  epiphyses  of,  547,  552 

—  fractures  of  lower  end  of, 

566,  590 

-  of  shaft  of,  565 
of  upper  end  of,  548 

—  shortening    of    limb 

after,  566 
nestra,  frontal,  31 
ovalis,  94 
rotunda,  94 


i 


Fenestra,  temporal,  31,  33 
Fibrous  polyp  of  nose,  113 

sheaths  of  flexor  tendons, 

321 
Fibula,  596 

—  absence  of,  604 

—  and    tibia,    fractures    of, 

602 

bone-grafts  from,  604 

— -  fractures  of,  603,  620 
Fifth    nerve,    72,    91,    104,    124, 
128,  132,  146,  150 

neuralgia   of,   12 

— =• paralysis  of,  63 

Filaria  sanguinis  hominis,  540 
Finger,      little,      "  congenital 
contraction  "  of,  322 

"  mallet-,"  329 

—  "  snap-,"  322 
Fingers,  avulsion  of,  333 

—  nerve  supply  of,  339,  341 
Fissure  of  Rolando,  45,  49 

—  of  Sylvius,  45 

—  parieto-occipital,  48 

—  spheno-maxillary,  33 
Fissures  of  brain,  43,  45 

—  of  Santorini,  88 

—  parietal,  20 
Fistula,  branchial,  209 

congenital,  87,  209 

gastric,  403 

—  in  ano,  478 

recto-vaginal,   508 

salivary,  139 

—  umbilical,  355 

—  vesico-vaginal,   508 
Flat-foot,  611,  630,  632 
Flexor  longus  hallucis,  609 

carpi  radialis  tendon,  310, 

324 
—  ulnaris  tendon,  311 

longus  digitorum  tendon, 

609 

tendons  of  wrist,  sheaths 

of,   321 

Fontana,  spaces  of,  77 
Fontanelle,  sagittal,  21 

—  temporary  occipital,  20 
Fontanelles,  17 

Foot,  607,  625 

—  abscess  of,  612 

amputations  of,  637 

arches  of,  625 

blood-vessels  of,  609,  616 

bony  points  of,  607 

—  bursBB  about,  614 

-  deformities  of.  628 

—  dislocations  of,  619 
— —  fascia  of,  609,  611 


684 


INDEX 


Foot,  fractures  of,  633 
-  imprints  of,  632 

—  integuments  of,  610 

nerves  of,  610 

-  joints  of,  625 

—  lymphatics  of,  617 

—  movements  of,  627 

-  muscles  of,  626 

-  perforating  ulcer  of,  611 

-  surface  anatomy  of,  607 

—  synovial  cavities  of,  637 

"  tread  "  of,  in  club-foot, 

630 
Foramen  caecum,  159 

—  incisivum,  112 

infraorbital,  125 

of  Key,  40 

—  of  Magendie,  40 
of  Monro,  40 

— -  of  Eetzius,  40 

—  of  Winslow,  391 

— —  ovale,    surface    markings 
of,  128 

—  supraorbital,  125 
Forearm,  301 

—  amputation  of,  308 

—  bones  of,  303 

—  fractures  of,  3.05 
—  luxations  of,  293 

—  surface  anatomy  of,  301 
vessels  of,  302 

Foreign  bodies  in  air-passages, 
195,  228 

in  bladder,  488.  490 

in  bronchi,  196,  229 

—  in  caecum,  418 
-  in  heart,  231 

in  nose.  108 

—  in  oesophagus,  201 

—  in  orbit,  59 

—  in  pharynx,  165 

—  in  rectum.  513 

—  in  stomach,  404 
—  in  trachea,  196,  228 

—  in   vitreous  humour, 

78 
Fossa  duodeno-jejunalis,  414 

—  hypophyseos,  33 

—  ileo-csecal,  422 

—  infraclavicular.  238 
• intersigmoid,  427 

ischio-rectal,  477 

—  navicularis.  496 

of  Rosenmuller,  100 

ovalis,  375.  534 

—  pterygo-palatine,  33 
retrocsecal,  422 

—  spheno-maxillary.  33 
Fossie,  nasal,  105 


Fourth  nerve,  paralysis  of,  62 
"  Fracture  hdlicoide,"  566,  603 
Fractures     (see     the    bones) 
Frenum  linguae,  15d 
Frontal  sinus,  116 

infundibuluni  of,  110, 

116,  117 

Froiito-malar  notch.  31 
Fronto-temporal  pillar.  31 
Fronto-zygomatic  notch,  31 
Funicular  process.  371 
• hernia  into,  372 

Galen,  veins  of,  40 
Gall-bladder,  433,  437 

excision  of,  437 

fundus  of,  433 

incision  into,  439 

—  nerve  supply  of.  438 

—  operations  on.  439 

—  relations  of.  433 
rupture  of,  439 

sphincter  of,  438 

vessels  of.  437 

Gall-stones,  437,  439 
Ganglion,    Gasserian,    excisioi 

of,   130.  155 

—  spheno-palatine,  125 
Gangrene  of  leg,  599 
of  intestine,  460,  461 

—  of  lung,  227 
Gasserian    ganglion,    excision 

of,  130,  155 

position  of,  16 

Gastrectomy.  407 
Gastric  fistula.  403 

ulcers,  403 

Gastrocnemius  muscle.  597 

rupture  of,  599 

Gastro-hepatic  omentum,  438 
Gastro-jejunostomy,  407 
Gastroplication.  408 
Gastrostomy,  404 
Gastrotomy.  404 
Generative  organs,  female,  5C 

male,  499 

Genito-crural  nerve,  538 
Genu  valgum.  585 

—  epinhvsis    of    fonu; 

in,  586 
Giantism.  42 

Gimbernat's  ligament,  378 
Gladiolus,  214 
Glans  penis,  499 
mucous      membrar 

of,  499 

Glaucoma,  78 
Glaucomatous  cup.  80 
Gle"nard's  disease,  393 


INDEX 


685 


Glenoid  cavity,  249,  263 
Slobe,  59  (see  also  Eyeball) 
jrlutoal  abscess,  528 

—  aneurysms,  530 

—  artery,  527,  530 

bursse,  520 

fascia,  527 

- — .  fold.  524 

—  muscle,  528,  529 

—  region,  523 

iJluteus  maximus,  528,  529 
rupture  of,  529 

goitre,  199 

Tcnorrhoea,  condition  of  ure- 
thra in,  498 

Granular  lids,  83 

Jreat  omentum,  387 

irreen-stick  fracture,  245 

Jroin,  region  of,  533 

Jroove  on    upper   surface   of 
first  cervical  rib,  185 

rubernaculum      testis,      rela- 
tions of.  370 

rullet  (see  (Esophagus) 

rummatous      periostitis      of 
sternum,  215 

fums,  153 

—  lymphatic  glands  of,  208 
ustatory  nerve,  153,  155 

.sematomata  of  scalp,  7 

—  on  pinna,  90 
sematuria,  448 
aemoptysis,  227 
a^morrhage  from  choroid,  67 

-  from  lung,  226 

I —  from  tongue,  155 

—  from  tonsil,  171 

—  from  uterus,  508 

—  from  vagina,  508 

—  into  vitreous,  71 

—  meningeal,  35 
Eemorrhoidal      vessels      and 

nerves,  478,  515 
.  Emorrhoids,   515 
emothorax,  226,  227 
Ulux  rigidus.  636 

—  valgus,  615 

im      (see      Knee,      popliteal 

space  of) 
immer-toe,  636 
imstring  muscles,  561,  563 
md,  312 
,  —  abscess  of,  320 

—  amputations  of,  333 

-  aponeuroses  of,  313,  319 
I—  blood-vessels  of.  326 

—  bones  of,  327 
creases  of,  323 


; 


Hand,  dislocations  of,  332 

—  dorsal  surface  of,  315 

—  fasciae  of,  313,  319 

—  fibrous  sheaths  of,  321 

joints  of,  327 

—  lymphatics  of,  327 

—  nails  of,  318 

—  nerve  supply  of,  317,  339 
palmar  surface  of,  312 

-  skin  of,  313,  315 

—  subcutaneous     tissue    of, 

317 

—  surface  anatomy  of.  312 

—  sweat-glands  of  palm  of, 

316,  339 

synovial  cavities  of,  332 

sacs  of,  323 

< sheaths  of,  323 

— -  tactile  sensibility  of,  317 
Hanging,  mode  of  death  from, 

Hard  palate,  162 

blood  supply  of,  162 

Hare-lip,  160 

Head     and    neck,     lymphatic 

glands  of,  206 
Heart,  229 

—  exposure  of,  231 

foreign  bodies  in,  231 

relations  of.  230,  402 

—  wounds  of,  231 

Heel,    integuments    of,    blood 

supply  of,  638 
—  nerve  supply  of,  638 
Hehcoidal  fractures,  566,  603 
Hepatic  abscess,  436 
Hereditary  syphilis,  18 
Hernia,  365 

caecal,  417 

congenital,  354,  365,  372 

—  diaphragmatic,  379 

direct,  369 

—  encysted,  372 

external,  368,  369 

—  fatty,  354 

—  femoral,  375 

—  indirect,  368,  369 

—  infantile,  372 
-  inguinal,  365 

—  internal,  369 

—  into     funicular     process. 

372 

—  ischio-rectal,  379 

—  lumbar,  379 

—  mesenteric,  414 

—  mesocolic,  414 

—  mesogastric,  414 

—  oblique,  368,  369 

—  obturator,  378 


686 


INDEX 


Hernia  of  lung,  226 
omental,  388 

perlneal,  379 

pudendal,  379,  507 

radical  cure  of,  374 

—  rare  forms  of,  379 

—  retroperitoneal,  414 

sciatic,  379 

—  sigmoid,  427 

strangulated,  427 

—  umbilical,  354,  379 
Hernise,  bladder  in,  485 
Hernial  sacs,  366 
Herniotomy    in    femoral    her- 
nia, 378 

in  inguinal  hernia,  374 

Herpes  zoster,  73,  362 
Hesselbach's  triangle,  369 
Hiatus  semilunaris,  110 
Highmore,  antrum  of,  119 
Hilua  of  kidney,  446,  453 
Hip,  dislocations  of,  553 

anatomy  of,  556 

congenital,  553 

modes    of    reducing, 

559 

region  of,  523 

Hip-joint,  540 

abscess  in,  542 

amputation  at,  559 

disease,  543 

chronic,  544 

mechanism  of  po- 
sitions of  limb 
in,  544 

. early  signs  of,  526 

dislocations  of,  553 

anatomy   of   each 

form  of,  556 

congenital,  553 

due  to  violence,  554 

—  general     facts     con- 
cerning, 554 

. modes    of    reducing, 

559 

effusion  into,  543 

•  fractures  about,  548 

movements  of,  542 

nerve  supply  of,  547 

—  relations  of,  541  (Pig.  118) 
Hippocratic  hand,  319 
Hirschsprung's  disease,  427 
Horseshoe  kidney,  452 

"  Hottentot  Venus,"  527 

Humerus,  237 

dislocations  of,  266 

epiphyses  of,  334 

excision  of  head  of,  274 

- fractures  of,  271,  280,  295 


of 


Humerus,  fractures  of,  de- 
layed u  n  i  o  11  or  non- 
union after,  281 

—  growth  of,  282 
Hunterian  chancre  on  corona, 

499 

—  on  glans,  499 
Hunter's  canal,  564 
Hyaloid  membrane,  75 
Hydatid  cysts  of  lung,  227 
Hydrencephalocele,  19 
Hydrocele,  503 
encysted,  of  cord,  372 

of  neck,  211 

Hydrocephalus,  17,  19,  40 
Hydronephrosis,  451 
Hyo-glossus  muscle,  175 
Hyoid  bone,  173 

—  accessory     glands 
about,  198 

bursa  near,  187 

fracture  of,  187 

Hypertrophy  of  prostate,  493 

—  of  pylorus,  406 

—  of  tonsil,   168 
Hypodermic        injection 

nerves,  127,  128.,  532 
Hypoglossal  nerve,  157 
Hypophysis,  41 
Hypopyon,  77 
Hypospadias,  500 
Hypothenar  eminence,  312 
Hysterical  hip,  547 
-  knee.  547 

Ileo-csecal  fossa,  422 

intussusception,  421 

orifice,  418 

region,  416 

sphincter,  398,  418 

valve,  421 

Ileo-colic  fossa,  422 

intussusception,  421 

Ileo-pectineal  ligament,  378 
Ileum,  408 

Iliac  abscess,  357,  382 

artery,  common,  350 

external,  350 

colon,  424 

multiple    diverticu!*' 

of  mucous  coat  oli 
427 

colotomy,  429 

fascia,  382 

glands,  internal,  540 

Ilio-psoas  muscle,  536 
Ilio-tibial  band,  529    571 
Imperforate  anus,  519 
Incisura  scapulans,  252 


INDEX 


687 


Indirect  hernia,  368,  369 
Infantile  hernia,  372 
Inferior  caval  point,  229 
dental  nerve,  127 

—  frontal  convolution,  47 

interosseous  ligament, 

620 
maxilla  (see  Mandible) 

mesenteric  artery,   350 

plexus,  459 

profunda  artery,  276 

temporal   convolution,   48 

thyroid  artery,  199 

—  vena  cava,  230,  461 
Infraclavicular  fossa,  238 
Infraorbital  artery,  126 

foramen,  125 

nerve,  125 

vein,  126 

Infundibulo  -  pelvic    ligament, 

509 
Infundibulum  of  frontal  sinus, 

110,  116.  117 
Inguinal  canal,  366 

—  in  female,  373 

colotomy,  429 

diverticula,  381 

—  glands,  534,  539 
hernia,  365 

ligament,  533 

Injection    into    subarachnoid 
space,  663 

-  intravenous,  287 

-  of  nerves,  127,  128.  532 
Innominate  bone,  465,  467 

—  vein,  205 
Intercarpal  joint,  328 
Intercostal  abscess,  218 

—  muscles,  218 

-  spaces,  217 

-  vessels,  218,  219 
Intercosto-humeral  nerve,  223 
Interscapulo-thoracic  amputa- 
tion, 252 

Intersigmoid  fossa,  427 
Interstitial  keratitis,  65 
Intertubercular  sulcus,  238 
Intervertebral  discs,  648 

—  veins,  234 

Intestinal     anastomosis,     416, 
430 

paralysis,  411 

spasm,  411 

Intestine,  large,  422  (see  also 
Colon) 

small,  408 

gangrene  of,  461 

• injury  to,  409 

length  of,  408 


Intestine,     small,     operations 
on,  415 

—  position  of,  409 

—  resection  of,  416 

—  strangulation  of,  412 
Intracranial  abscess,  12 
Intravenous  injections,  287 
Intussusception,  411,  421 
Inversion  movements,  627 

i    Iridectomy,  69.  79 

Iris,  64,  68 
I    Iritis,  68 

i    Ischsemic  contraction,  307 
j    Ischial  spine,  527 

—  • as    guide    to    ureter, 

458 

Ischio-rectal  abscess,  477,  478 
fossa,  477 

—  hernia,  379 
Ischio-sacral  arch,  465 
Island  of  Reil,  48 

Islets  of  Langerhans,  445 
Isthmus  of  thyroid,  194,  198 

Jaws      (see      Mandible      and 

Maxilla) 
Jejunum,  408 

Joints,    surgical   classification 
of,  262 

—  (see  also  name  of  each) 
Jugular  vein,  external,  176 

internal,  95,  168,  172, 

204 

Keratitis,  interstitial,  65 
Key,  foramen  of,  40 
Kidney,  445 

—  abnormalities  of.  450 

—  abscess  of,  448 

—  adherent,  454 

—  development  of,  451 

—  fusion  of,  452 

hilus  of,  446,  453 

—  horseshoe,  452 

—  movable,  449 

—  nerve  supply  of,  450,  522 
— •  operations  on,  452 

—  pelvis  of,  446,  456 

—  position  of,  445 

—  relations  of,  445 

—  rupture  of,  447 

—  "  sacral,"  451 
support  of,  449 

—  surface  anatomy  of,  445 

—  tumours  of,  453 

vessels  of,  350,  453 

Knee,  569 

-  front  of,  572 
blood  supply  of,  573 


688 


INDEX 


Knee,    front   of,    bursge    over, 

573 

skin  of,  572 

subcut  a  n  e  o  u  s    fat 

over,  572 

lymphatics  of,  573 

pain     in,      in     hip-joint 

disease,  547 

popliteal  spa.ce  of,  571,  574 

abscess   in.   574 

bursse  about,  578 

fascia  of,  574 

—  lymphatic 
glands  of,  577 

—  muscles  and  ten- 
dons of,  575 

skin  of,  574 

vessels    of,    571, 

575 

- —  surface  anatomy  of,  569 
Knee-cap  (see  Patella) 
Knee-joint,  579 
amputation   through,   596 

ankylosis  of,  579 

•  derangement  of,  582 

disease,  575,  582 

dislocations  of,  589 

excision  of,  592 

—  exploration  of,  592 

fracture  about,  590 

ligaments  of,  crucial,  579, 

581 

. lateral,  579 

—  rest  for,  to  secure,  594 

synovial    membrane    of, 

580 
Knock-knee,  585 

epiphysis    of    femur    in, 

586 

"  Knock-out "  blow,  27 
Kraske's  operation,  516 
Kyphosis,  213 

Labia  majora,  507 
Labial  arteries,  151 

nerves,  153 

Labyrinth  of  ear,  102 
Lacrimal  abscess,  84 

apparatus,  83 

arteries,  70 

gland,  83 

sac,  84 

Lacuna  magna,  urethral,  498 
Lambda,  17 
Lambdoid  suture,  17 
Lamina  cribrosa,  67 

fusca,  67 

suprachoroidea,  67 

Laminectomy,  657 


Laiigerhans,  islets  of,  445 
Larynge"al    lymphatic   glands, 

206 

Laryngotomy,   195 
Larynx,  187 

aperture  of,   upper,   189 

cartilages  of,  188 

fracture  of,  188 

cords  of,  189 

excision  of,  191 

—  foreign  bodies   in,   195 

—  lymphatic      glands      and 

vessels  of,  192,  208 
— -  mucous  membrane  of,  190 
Lateral  curvature,  213 

ligament    of     elbow,    in- 

ternal, 290,  292 

ligaments    of    knee-joint, 

579 
muscles  of  abdomen,  356 

—  sinus,  10,  36 

ventricles,  48 

Leg,  596 

—  aching,  600 

amputation  of,  605 

fascia  of,  598 

fractures  of,  602 

gangrene  of,  599 

nerve  supply  of,  641 

—  pain  in,  601 

rickets  affecting  bones  of. 

604 

skin  of,  597 

—  surface  anatomy  of,  596 

varicose  veins  of,  599 

vessels  of,  597,  599 

Lens,  74, 

—  artery  to,  78 

capsule  of,  74,  75 

Levator  ani,  471,  512 

palati,  163,  165 

palpebrse,  81 

Ligamenta  subflava,  657 
Ligamentum  laciniatum,  612 

patellee.  569,  581 

pectinatum  iridis,  76 

"Lighterman's  bottom,"  530 
Linea  alba,  348,  353 

semilunaris,   348 

Lineae  transversse,   348 
Lingual  artery,  154,  155,  171 

nerve,  153,  155 

Linguiform  process,  434 

Lip,  lower,  lymphatic  glands 

of,  208 
Lipomata  in  deltoid  region,  262 

in  femoral  triangle.  535 

in  suprahyoid  region,  178 

on  buttocks,  527 


INDEX 


689 


Lipomata,  rarity  of,  on  face, 

122 

;Lips,  150 

Lisfranc's  operation,  639 
Litholapaxy,  482 

. •  in  children,  482 

Lithotomy,  perineal,  482 

suprapubic,  482 

Liver,  432 

| abscess  of,  436 

r disease  of,  459,  462 

—  fixation  of,  434 

—  in  pyaemia.  436 

—  nerve  supply  of,  459 

—  operations  on,  436 

, parietal  surface  of,  432 

— -  ptosis  of,  434 

—  relations  of,  432 

— • to   transverse   colon, 

435 

—  rupture  of,  434 

—  variations  in  form  of,  434 

visceral  surface  of,  432 

— —  wounds  of,  435 

—  zones  of,  432 
localization  of  sensori-motor 

areas  of  brain,  48 
Lrockjaw,  147 
Longitudinal   sinus,   superior, 

36 

jjongus  colli  muscle.  649 
jXirdosis  in  hip-joint  disease, 

545 

jower  limb,  lymphatics  of,  539 
— -  limbs,  unequal  length  of, 
568 

nerve  supply  of,  641 

umbar  abscesses,  385 

—  colotomy,  424 

—  fascia,  385 
glands,  460,  540 
hernia,  379 

puncture   into    subarach- 
noid  space.  663 

—  region,  384 
•  of  spine,  649 

injuries  in,  651. 

652,  656 

—  rib,  657 

—  triangle,  384,  385 

—  vertebrae,    operation    for 

caries  of,  385 

transverse   processes 

of,  fracture  of,  657 
ung,  224 

apex  of,  in  neck,  224 

—  cavities,  drainage  of,  227 


—  collapse  of,  226,  227 
—  haemorrhage  from,  226,  227 


Lung,  hernia  of,  226 
hydatid  cysts  of,  227 

relations   of,   to   surface, 

225 

root  of,  exposure  of,  229 

rupture  of  air-vesicle  of, 

226 

wounds  of,  225,  435 

Lupus  erythematosus,  103   ' 
Luschka's  tonsil,  100 
Lymphangioma     cavernosum, 

158 

Lymphatic  glands  and  vessels 
(see  various  regions) 

McCurdy's  line,  524 
Macroglpssia,  158 
Magendie,  foramen  of,  40 
Malar  angle,  31 

bone,  133 

Malleoli,  607 

"  Mallet-finger,"  329 

Mamma,  21y 

arteries  of,  219,  223 

cancer  of,  222,  509 

capsule  of,  221 

development  of,  220 

in  femoral  triangle,  535 

influence    of    ovary    on, 

509 

lymphatics  of,  221 

Mammae,   supernumerary.   223 
Mammary     artery,     internal, 

219,  232 
Mandible,  141 
•  deformities  of,  146 

dislocation  of,  143 

excision  of,  145 

fracture  of,  141 

nerves  of,  146 

subluxation  of,  144 

Mandibular  joint,  143 

dislocation  of,  144 

Manubrium,  214 
Mastication,  muscles  of,  147 
Mastoid  antrum,  95 
perforation  of,  98 

cells,  98 

—  lymphatic  glands,  206 
Masto-parietal  pillar,  33 
Maxilla,  139 

excision  of,  140 

fracture  of,  139 

necrosis  of,  139 

nerves  of,  146 

—  periosteum  of,  139 
Maxillary     artery,     internal, 

162,  171 

—  sinus,  119 


690 


INDEX 


Meatus,  auditory,  external,  33, 

88 
blood  supply  of, 

90 
—  nerve  supply  of, 

90 
internal,  33 

—  of  urethra,  497 
Meatuses  of  nose,  110 
Meckel's  diverticulum,  355,  411 

—  ganglion,  125 

—  space,  131 

Medial   cutaneous    nerve,   276, 

277,  288 
Median  artery,  326 

basilic  vein,  284,  287 

cephalic  vein,  284,  287 

commissure   of    prostate, 

491 

-  nerve,  300,  303 
paralysis  of,  345 

section  of,  345 

Mediastina,  abscess  of,  215,  232 

glands  of,  206 

tumours  of,  234 

Mediotarsal  joint,  624 

ampatation  at,  639 

Medulla  spinalis   isee    Spinal 

cord) 

Meibomian  glands,  81 
Membrana  tympani,  91 
Membranous  urethra,  480,  497 
Meningeal  vessels.  12,  35 

haemorrhage,  35 

trephining  for,  12 

Meninges  of  brain,  34 
spread  of   inflamma- 
tion to,  from  nose, 
108,  109 

of  spinal  cord,  659,  660 

Meningitis    from    abscess    in 
ear,  89,  95 

from      inflammation      of 

nasal  fossae,  108,  109 

spinal,    from    bed  -  sores, 

661 

Meningocele,  19.  105,  109 
— •  spinal,  673 
Meningo-myelocele,  673 
Menisci   (see  Semilunar  carti- 
lages) 

Mercier's  bar,  490 
Mesenteric  arteries,  350,  460 
hernia,  414 

plexus,  459 

Mesentery,  389 

attachment    of,    leakage 

along,  after  operation, 


Mesentery,  holes  in,  390 

-  imperfect  attachments  of, 

390 

-  length  of,  389 

-  of  appendix,  419 
Meso-appendix.  419 
Mesocolic  hernia,  414 
Mesocolon,  424 
Mesogastric  hernia,  414 
Mesohepar,  434 
Metacarpo-phalangeal  joint  of 

thumb,  dislocations  at,  332 
Metatarsal  bones,  fractures  of, 

635 
Metatarso-phalangeal     joints, 

608,  614 

Micturition  in  spinal  injuries, 
671 

—  mechanism  of,  483 
Midcarpal  joint,  328 
Midcolic  sphincter,  398 
Middle  ear,  inflation  of,  99 
--  lymphatics  of,  101 
--  meningeal  artery,   12,  35 
Middle-ear     disease,     cerebral 

abscess  in,  48 

Midepigastric  point,  349,  394 
Midhypogastric  line,  394 

-  point,  394 
Midtarsal  joint,  608 
Midzygomatic  point,  31,  33 
"  Miner's  elbow,"  290 
Monro,  foramen  of,  40 
Monro's  point,  395 
Morgagni,  columns  of,  518 
Motor  centres.  44,  49 
--  paralysis   of,    in 

juries  to  cord, 
Mouth,  150 

-  cysts  in  floor  of,  153 

-  dermoid  cysts  of,  153 
--  lymphatic  glands  of,  208 

—  •  thyroid  cysts  of,  153 
Movable  kidney,  449 
Mucous    membrane    (see 
various  regions) 

—  polyp  of  nose,  113 
Multiangulum  majus,  312 
Multifidus  spinse  muscles,  649, 

650 

Muscles,  functional  classifica- 
tion of,  328 

-  (see  also  name  of  each) 
Musculo-cutaneous  nerve,  276, 

610 

Musculo-spiral  nerve,  276,  337 
----    paralysis  of,  279,  344 
Myxoedema,  199 
Myxomatous  polyp  of  nose,  113 


in- 
670 


the 


INDEX 


691 


Nails  of  hand,  318 
Nares,  anterior,  105 

—  posterior,  106 
Nasal  cavities,  105 

blood  supply  of,  113 

floor  of,  111 

in  children,  107 

—  lymphatic  glands  and 

vessels  of,  115,  208 

•  mucous      membrane 

of,  112 

nerves  of,  114 

outer  walls  of,  110 

—  roof  of.  109 

septum  of,  109 

—  spread  of   inflamma- 
tion from,  108 

douche,  108 

• duct,  86 

nerve,  71,  73 

-  polypi,  113 

sinuses,  115 

— -  (see  also  Nose) 
Naso-lacrimal  duct,  86 
Navel  (see  Umbilicus  and  Um- 
bilical) 
Navicular  bone,  607 

fracture  of,  331 

Neck,  173 

abscess  of,  182 

—  air-sac  in,  211 

—  apex  of  lung  in,  183 

blood-vessels  of,  175.  204 

—  bony  points  of,  173 

fasciae  of,  179 

-  fistulae  of,  209 
hydrocele  of,  211 

-—  lymphatic  glands  of,  206, 

208 
middle  line  of,  174 

muscles  of,  174 

—  nerves  of,  177 

ribs  in,  183 

side  of.  174 

skin  of,  178 

surface  anatomy  of,  173 

thoracic  duct  in,  208 

—  wounds  of,  185 
Necrosis  of  maxilla,  140 

of  skull,  5,  21.  157 

Nelaton's  line,  524 
Nephrectomy,  452 
Nephrolithotomy,  452 
Nephrorrhaphy,  452 
Nephrotomy,  452 
Nerve-injecting,  127,  128,  532 
Nerves,  breaking-points  of,  531 
division   of    (see    various 

trunks) 


Nerves,  sensory,  effects  follow- 
ing section  of,  128 

—  (see  also  various  regions) 
Nerve-stretching,  531 
Neural  arches.  673 
Neuralgia,  facial,  125 
Neuritis,  optic,  76 

Nipple,  220 

Nipples,  supernumerary,  223 

Nose,  103 

bleeding  from,  113 

—  bones  of,  fracture  of,  104 

—  cartilaginous  part  of,  104 

—  foreign  bodies  in,  108 

—  mucous  membrane  of,  112 
skin  of,  103 

—  (see  also  Nasal) 
Notch  of  Rivini,  92 
Nuck.  canal  of,  373 
Nutrient  artery,  276 

Oblique,  inferior  and  superior, 

muscles,  60 
internal     and     external, 

muscles,  649 
Obturator    artery,    abnormal, 

377 

—  canal,  378 

—  dislocation,  557,  559 
fascia,  472 

—  hernia,  378 

—  nerve,  548 

— paralysis  of,  644 

Occipital  artery,  176 

—  bone  at  birth.  19 
necrosis  of,  157 

—  fontanelle,  temporary,  20 

—  lymphatic  glands,  206 

nerve,  small,  177 

Occlusion  of  duodenum,  414 
Oculo-motor  nerves,  paralysis 

of,  63 

Odontoid  process,  657 
CEsophagotomy,   202 
(Esophagus,  199 

cancer  of,  202 

—  curves  of,  200 

—  foreign  bodies  in,  201 
— -  malformations  of,   202 

—  nerve  supply  of,  202 

—  relations  of,  201 

—  sphincters  of,   200,  396 
Olecranon,  285 

—  epiphysis  of,  299 

—  fractures  of,  298 
Olfactory  nerves,  114 
Omega  loop  of  colon,  425 
Omental  hernia,  388 

sac,  388 


692 


INDEX 


Ouientum,  gastro-hepatic,  438 

—  great,  387 
Omo-hyoid,   175 
Onychia,  318 

Ophthalmia,   sympathetic,   74 
Optic  disc,  76 

—  foramen,  33,  76 

—  nerve,   61,  75 
neuritis,  76 

—  thalamus,  48 
Ora  serrata,  75 
Orbicularis  oculi,  85 
Orbit,  55 

abscess  in,  59 

arteries  of,  61 

bones  of,  55 

fasciae  of,  57 

foreign  bodies  in,  59 

-  lymphatic  glands  of,   208 

—  muscles  of,  59 

nerves  of,  61 

—  paralysis  of,  62 

— —  relations  of  walls  of,  56 

—  tumours  in,  56 

pulsating,  61 

Orbitalis  muscle,  64 
Os  calcis,  607,  608 

—  fractures  of,  634 
ossification   of,    635 

capitatum,  332 

innominatum,  467 

• magnum,    dislocation    of, 

332 

—  trigonum,  634 
Osseous  labyrinth,  102 
Ossicles  of  ear,  93 
Ovario-pelvic   ligament,   509 
Ovary,  509 

—  lymphatics  of,  509 
nerves  of,  509 

—  trophic  influence  of,  509 
— -  vestigial    structures    con- 
nected with,  509 

Pacinian  bodies  in  foot,  610 

in  hand,  317 

Paget's  disease,   220 
Pain,  sensation  of,  338 
Palate,  160 

cleft,  160 

development  of,  160 

hard,  162 

lymphatic  glands  of,  208 

—  soft,  163 
Palmar  abscess,  320 

aponeurosis,  313,  319 

arches,  327 

—  surface,   312 
Palmaris  longus  tendon,  310 


Pampiniform  plexus,  506 
Pancreas,  443 

—  cancer  of,  444 

internal  secretion  of,  445 

—  relations  of,  443 
Pancreatic  ducts,  443 
Pannus,  66 

Paracentesis    of    pericardium. 
232 

—  of  thorax,  217 
Paralysis    in    spinal    injuries, 

670 

—  of  anterior  crural  nerve, 

641 

of  biceps,   245 

of  brachial    plexus,    344 

of  brachialis   muscle,    245 

.of  brachio-radialis     mus- 
cle, 245 

—  of    cervical    sympathetic, 

of  Erb,  259 

—  of    external    popliteal 

nerve,  645 

of  facial  nerve,  85,  137 

—  of  first    division    of    fifth 

nerve,   63 

of  fourth  nerve,  62 

of  great  sciatic  nerve,  645 

of    internal    popliteal 

nerve,  645 

of    long    thoracic    nerve, 

251 

—  of  median   nerve,  345 

—  of  musculo-spiral    nerve, 

279,   344 

—  of  obturator   nerve,    644 

—  of  oculo-motor  nerves,  63 

—  of  orbital  nerves,  62 

—  of  peroneal   nerve,   645 

- — -  of  rhomboid  muscles,  251 
of  sixth  nerve,  62 

—  of  small  intestine,   411 
of  third  nerve,  62 

—  of  tibial  nerve,  645 

—  of  trapezius  muscle,  250 

—  of  ulnar  nerve,  280,  346 
Paralytic  ileus,  411 
Parasinoids,  36 

Parasitic  foetuses,  470 
Parathyroid  bodies,  198 
Parietal  bone,  relations  of,  20, 

45 

— -  fissures,  20 
Parieto-occipital   fissure,    48 
Paronychia,  318,  324 
Parotid  abscess,  136 
duct,  138 

—  fascia,  134 


INDEX 


693 


Parotid  gland,  133 

• lymphatic  glands,  206 

nerve  supply,  135 

region,  133 

structures,  136 

—  tumours,  138 
Pars  triangularis,  47 
Patella.  568 

-  blood  supply  of,  589 

—  congenital  absence  of,  583 

—  development  of,   588 
— -  dislocation  of,   589 

—  fractures  of,  586 
Patellar  bursa,  573 

—  ligament,  569,  581 
Pectoral  glands,  221 
Pectoralis  major,  239 

—  minor,  239 
Pelvic  abscess,  542 

—  colon,  425 

—  multiple1  diverticula 

of  mucous  coat  of, 
427 

urethra,  495 

—  vise  era,    fixation    and 

movements  of,  473 

—  nerves  of,  520 
Pelvis,   465 

—  arch  of,  445 

fascia  of,  471 

-  floor  of,  471 

—  fractures  of,  466 

—  mechanism  of,  465 
—  nerves  of,  520 
renal,  446,  456 

—  rickety,  466 

—  small  intestine  in,  409 

—  subserous  tissue  of,  474 
Penile  urethra,  495,  497 
Penis,  499 

abnormalities  of,  500 

—  lymphatics  of,  500 

skin  of,  499 

—  nerves  of,  521 

subcutaneous     tissue     of, 

499 

—  vascularity  of,  499 
Perforating  ulcer  of  foot,  611 
Pericardium,  229 

—  paracentesis  of,  232 
Pericranium,   5 
Perineal  fascia,  479 
hernia,   379 

-  lithotomy,  482 

—  urethra,   495 
Perinephritic  abscess,  448 
Perineum,  male,  475 

_  _ —  depth  of,  477 
nerves  of,   520,   521 


Periosteum,  5 
Perirenal  capsule,  449 

—  opening  of,  453 
-  fat.  448 

Peristalsis  in  alimentary 
tract,  390 

—  in  ureter,  456 
Peritoneal       communications, 

390 

—  spaces,  390 
Peritoneum,  386 

—  fossae  of,  368,  421 

—  relations    of    bladder    to, 

486,  487 

watersheds  of,  391 

Peritonitis,  386 

Peroneal  artery,  597,  599,  610 

muscles,  597 

—  nerve,   571,  575,   601,   609 
paralysis  of,   645 

—  retinaculum,  613 

—  tendon,  608 

—  tubercle,  608 
Pes  cavus,   611,  633 

Petit's   triangle,   349,   384,  385 
Petro-squamous   suture,    95 

-  vein,  95 
Phalanges    of    toes,    fractures 

of,  635 

Phalanx  of  great  toe,  disloca- 
tion of,  635 
Phantom  tumour,  355 
Pharyngeal  artery,  ascending, 

172 
— -  orifice,  99,  100 

—  pouches,  202 

—  recess,  100 

—  sphincter,  396 

—  tonsil,  100 
Pharynx,  165 

—  dimensions  of,  165 

—  foreign  bodies  in,  165 

—  lymphatic   glands   of,   208 

—  mucous  membrane  of,  165 

—  nerves  of,  168 

—  relations  of,  166 
Phlebitis  of  femoral  vein,  538 
Phleboliths,  458 
Photophobia,  72 

Phrenic  nerve,  177,  228 
Pia  mater,  38,  666 
Pigeon  breast,  212 
Piles,  515 
Pinna,  87 

Pirogoff's  amputation,  638 
Pituitary  body,  41 
access  to,  42 

—  fossa,  33 

—  tumours.  43 


694 


INDEX 


Plantar  arch,  wounds  of,  616 

maintenance   of,    626 

arteries,   609 

fascia,  609,  611 

nerves,  610 

— •  (see  also  Foot) 

Plantaris  tendon,  rupture  of, 

599 

Platysma  myoides,  178 
Pleura,  225 

—  nerve  supply  of,  228 

—  opening  of,  453 

relations    of,    to    surface, 

225 

—  wounds  of,  183,  225 
Pleural  adhesions,  227 
Plica  semilunaris,  170 

—  triangularis,  170 

vascularis,    relations     of, 

371   (Pig.  83) 
Pneumatoceles,  98 
Pneumothorax,  225 
Politzer's  method  of  inflating 

middle  ear,  99 
Polypi,  nasal,  113 
Popliteal  artery.  571,  576,  597 

—  aneurysm  of,  576 

—  nerve,  572 

—  paralysis  of,  645 

—  space  (see  Knee,  popliteal 

space  of) 
—  vein,  577 

Portal  circulation,  388,  461,  462 
Postauricular     lymphatic 

glands,  206 

Postcentral  convolution,  49 
Posterior  nares,  106 
Postnasal  growths.  167 
Postnephric  fascia,  449 
Postpharyngeal    abscess,    135, 

168 

Postural  reflexes,  611 
Pott's  disease,  212,  361,  658 

fracture,  622 

Poupart's  ligament,  348,  533 
Preauricular       lymphatic 

glands,  206,  208 
Precentral  convolution,  49 
Premeatal  point,  31,  33 
Prenephric  fascia.  449 
Preputial  ocelli,  501 
Prevesical  space,  485 
Processus  funicularis,  371 

vaginalis.  369,  371,  374 

Pronation,  304 
Prostate,  480.  491 

—  abscess  of.  493 

< capsule  of,  492 

commissures  of,  491 


Prostate,  ducts  of,  491 
— -  hypertrophy  of,  493 

lobes  of,  491 

—  lymphatics  of,  495 

—  nerves  of.  493 

secretion  of,  491 

sheath  of,  482,  492 

Prostatectomy,  494 
Prostatic  urethra,  496 

utricle,  498 

venous  plexus,  481,  493 

Prostatitis,  493 

Protopathic    sensibility,     129, 

338,  346  . 
Pruritus  ani,  518 
Psoas  abscess,  384,  536 

muscle,  536 

Pterion.  14,  45 

Pterygoid     muscle,     external, 

144 
Pterygo-mandibular  ligament, 

153 

Ptosis  of  eyelid.  62 
-  of  liver,  434 

—  of  stomach,  400 

Pubes.   dislocation   upon,   554, 

557,  559 

Pubic     commissure    of     pros- 
tate, 491 
line,  524 

spine,  348 

Pudendal  hernia,  379,  507 
Pudic  artery,  527 

— -  nerve.  520,  521 
Pulmonary  apoplexy,  227 
Pupillary  membrane,  69 
Pyaemia,  liver  in,  436 
Pyloric  orifice,  399 

—  sphincter,  396,  406 

—  hypertrophy  of,  406 
Pyloroplasty,  408 
Pylorus,  400,  406 

—  cancer  of,  444 

resection  of,  406 

Quadratus  lumborum  muscle, 
649 

Quadriceps,  tendon  of.  rup- 
ture of,  564 

Radial  artery.  302.  327 

nerve,  276,  337,  341 

paralysis  of,  279,  344 

Radio-carpal  joint,  311,  328 
Radio-diagnosis  (see  X-ray  ex- 
amination) 

Radio-humeral  joint,  285 
Radius,  dislocation  of.  293 
—  fractures  of,  299,  305 


INDEX 


695 


Radius,    relations   of,    with 
uliia,  303 

surface  markings  of,  302 

Ranula,  152 

acute,  153 

Rectal    commissure    of    pros- 
tate, 491 
Recti,  divarication  of,  353 

—  muscles  (eyeball),  59 
Rectocele,  vaginal,  507 
Recto-colic    sphincteric    tract, 

398 

Recto-epigastric  triangle,  369 
Recto-vaginal  fistula,  508 

—  wall,  rupture -of,  519 
Recto-vesical  pouch,  486,  511 
septum.  493 

Rectum,  510 

attachments  of,  473,  514 

^ cancer  of,  516 

—  congenital  absence  of,  427 

—  deficiency  of,  427 
— -  malformations  of,  520 

—  distension    of,    in    supra- 

pubic  lithotomy,  513 

—  division    of,    into    upper 

and  lower  parts,  512 
excision  of,  516 

—  folds  of,  514 

foreign  bodies  in,  513 

—  in  female,  512 
— -  in  infant,  427 

—  introduction     of     hand 

into,  513 
— —  lymphatics  of.  515 

—  mucous  membrane  of,  514 

—  nerve  supply  of,  517,  520 

—  serous  membrane  of,  511 
— -  valves  of,  514 

vessels  of.  514 

Rectus  abdominis"  muscle,  348, 
355 

femoris  muscle,  561 

Recurrent     laryngeal     nerve, 

199 

Referred  pain,  146,  344,  361, 
459,  469,  547,  601,  619 

Reflex  contraction  from  vis- 
ceral disease,  356 

Renal  abscess,  448 

—  artery,  453 

pelvis,  446.  456 

plexus,  450 

— — -  tumours,  453 

—  (see  also  Kidney) 
Respiration  in  spinal  injuries 

670 

Respiratory  exercises  in  pos- 
tural defects,  650 


Respiratory      movements      as 

by 

Rete  testis,  510 
j    Retina,  75 

vessels  of,  71 

Retrocaecal  fossa,  422 
Retromalar  area,  32 
Retroperitoneal  hernia,  414 
Retropharyngeal  abscess,  115 
Retropubic  abscess,  485 

space,  485 

Retzius,  foramen  of,  40 
Rhinoplasty,  103 
Rhinoscopy,  posterior,  106 
Ribs,  215 

cervical,  183 

effect  of  rickets  on,  217 

—  excision  of,  218 

—  fractures  of,  216 
Rickets,    effect    of,    on    pelvis, 

466 

-  on  ribs,  217 
—  on  skull,  18 

— on  tibia,  604 

Rickety  pelvis,  466 

— -  rosary,"  217 
Rider's  bone,  533 

sprains,  533 

Riedel's  lobe,  $34 
Rima  glottidis,  174,  189 
Rivini,  notch  of,  92 
Rolando,  fissure  of,  45,  49 
Rontgen    rays    (see   X-ray    ex- 
amination) 

Rosenmtiller,  fossa  of,  100 
Rotatores  spinae  muscles,  649 
Rouge's  operation,  106 

Sacculated  bladder,   489 
Sacro-coccygeal  joint,  disloca- 
tion of,  470 

tumours,  470 

Sacro-iliac  joint,  465 
disease    of,    referred 

pains  in,  469 

exposure  of,  469 

nerve    relations    of, 

469 
Sacro-sciatic  foramen,  533 

notch,  458 

Sacrum,  465 

dislocation  of,  470 

Sagittal  fontanelle,  21 

—  suture,  17 
Salivary  fistulas,  139 
Santorini,  dnct  of,  443 

—  fissures  of,  88 
Saphenous  nerve,  572,  597,  610 

—  opening,  376,  534 


696 


INDEX 


Saphenous  veins,  532,  572,  577. 

597,  600 
Sarcomatous    polyp    of    nose, 

Sartorius  muscle,  533,  537,  561 

dislocation  of,  564 

Scalene  muscles,  175,  649 
Scalp,  1 

abscess  of,  6,  8 

blood  tumours  of,  7 

blood-vessels  of,  6 

—  connective   tissue   of,    3 
cysts  of,  2 

dangerous  area  of,  3 

erysipelas  of,  10 

—  fascia  of,  1,  6 

—  fatty  tissue,  2 

—  heematomata  of,  7 

lymphatic  glands  and  ves- 
sels of.  12,  206 
-  mobility  of,  3 

—  nerves  of,  12 

— • —  sebaceous  tumours  of,  2 
skin  of,  1 

—  subcutaneous  tissue  of,  1 

—  suppuration  in,  6 

—  temporal  region  of,  7 

—  vascularity  of,  4 

wounds  of,  3 

—  bleeding  from,  4 
Scaphoid.  607 
fracture  of,  331 

ossification  of,  635 

Scapula.  236,  238.  249 

—  excision  of,  252 

fracture  of,  251 

of  body  of,  252 

through    surgical 

neck  of,  252 

—  movements  of.  250 

—  tumours  of,  252 

—  "  winging  "  of,  251 
Scapular     artery,      posterior, 

253 
Scarpa's  fascia,  177 

—  triangle      (see      Femoral 

triangle) 

Schlemm,  canal  of,  77 
Sciatic  artery.  527,  530 

—  hernia,  379 

• nerve,  great,  527,  530,  531, 

644 

paralysis  of,  645 

. relations  of,  530 

small,  520,  521 

notch,     dislocation     into, 

554,  556 

Sciatica.  530,  532 
Sclera,  66 


Scoliosis,  213,  650 
Scrotum,  501 

oedema  of,  502 

—  lymphatics  of,  504 

rugae  of,  501 

—  skin  of,  501 
nerves  of,  521 

subcutaneous     tissue     of, 

502 

Sebaceous  tumours  of  scalp,  2 
Semilunar  cartilages,  disloca- 
tion of,  582 

mechanics  of,  582 

ganglion    (see    Gasserian 

ganglion) 

Semimembranosus  tendon,  571 
Semispinalis  muscle,  649 
Semitendinosus  tendon,  571 
Sensory  areas  of  brain,  44,  50 

nerve,     effects     following 

section  of,  128 

paralysis    in    injuries    to 

cord,  670 

Septum  of  nose,  109 
Sesamoid  bones,  607 
Short-circuiting,  416,  430 
Shoulder,  236 

— -  surface  anatomy  of,  236 
Shoulder-joint,  262 

—  amputation  at,  273 

—  ankylosis  of,  250 

—  bursae  about,  264 

—  capsule  of,  264 

—  disease  of,  265 

dislocation  of,  266 

common  features  of, 

267,  268 

special    anatomy    of 

various    forms    of, 
269 

—  fractures  about,  271 
Sibson's  fascia,  183 
Sigmoid  hernia,   427 

-  loop,  425 

—  mesocolon,  425 
Sinus,  cavernous,  37 

-  frontal,  116 

—  lateral,  36 

—  maxillary,   119 

pocularis,  477 

sphenoidal,  33,  118 

—  superior  longitudinal,   36 
Sinuses,  nasal,  115 

Sixth  nerve,  paralysis  of,  62 
Skull,  17 

abnormalities  of,  19 

at  birth.  20,  30 

—  bony  vault  of.  17 
.  cap,  thickness  of,  30 


INDEX 


697 


Skull,  contents  of,  34 
—  deformities  of,  19 
development  of,  18 
effect  of  rickets  on,  18 
emissary  veins  of,  9 

fontanelles  of,  17 

fractures  of  base  of,  27 

mechanics  of,  25 

vault  of,  26 

natiform  elevations  of,  18 
necrosis  of,  5,  21 

of  infant,  17,  23,  30 
parietal  fissures  of,  20 
pillars  of,  24 
soft  parts  covering,  1 

surface-points  of,  31 

sutures  of,  17,  20 
closure  of,  24 

separation  of,  29 

temporal  region  of,  X-ray 

examination  of,  31 
thickness  of,  30 
trephining,  12 
venous  tumours  of,  10 
violence  applied  to,  anato- 
mical conditions    mini- 
mizing, 24 
Smith's    (Stephen)    operation, 

595 

'  Snap  "-finger,  322 
'  Snuff-box,"  315 
Soft  palate,  163 

blood  supply  of,  164 
muscles  of,   163 

—  nerves  of.  165 
>olar  plexus,  443,  458 
Sole,  skin  of,  postural  reflexes 

from,  610 
Soleus  muscle,  597,  599 
Somatic   spinal  centres,  363 
Spaces  of  Fontana,  77.  78,  79 
Spasmodic  stricture,  497,  521 
Speech,  motor  centre  for,  47 
Spermatic  cord,  504 

arteries  of,  505 

veins.   505 
^phenoidal  sinus,  33,  118 
Spheno-palatine  ganglion,   125 
Sphincter  ani,  518 

urethra,  495,  496.  497 
^phincteric  points  of  aliment- 
ary canal,  396 
ipina  bifida,  672 
Spinal  accessory  nerve,   177 
analgesia.  663 
arachnoid,  661 
centres     for      abdominal 
viscera. 363.  364 
wall,  359,  362 


Spinal  centres  for  skin  areas 
of  lower  extremity,  641, 
646 

cord,  659 

—  blood  supply  of,   666 

—  concussion  of,  666 
contusion  and  crush- 
ing of,  667 

loss   of   motion    and 

sensation    due    to 
injury  of,  670 
operations  on,  674 

pressure    effects    on, 

667 

protection  of,  653 

—  segments  of  (see  Spi- 
nal centres) 

wounds  of,  187,  665 

dura  mater,  659,  660 

injuries   and   defaecation, 

672 

and  micturition,    671 

and  respiration,    670 

and  upper  limb,  339 

and  vomiting,  672 

—  meninges,  659,  660 

—  meningitis,  661 

—  meningocele,  673 

meningo-myelocele,    673 

muscles,  649 

nerves  of  abdomen.   362 

of  lower  limb,  641 

—  points     of     exit     of, 

from    v  e  r  t  e- 

bral  canal,  669 

of  origin  of,  669 

—  pia  mater,  666 
Spine,  647 

anterior  superior,  349 

—  caries  of,  385,  658 

—  curves  of.  213,  647 
dislocations  of,  652 

fracture  -  dislocations    of, 

655,  670 

—  fractures  of,  652 

how  maintained  erect,  649 

kyphosis  of,  213 

mechanism  of,  652 

movements  of,  638 

—  of  infant.  648 

—  pubic,  348 

resection    of    laminae    of. 

657 

—  scoliosis  of,  213,  650 

—  sprains  of,  650 

—  trephining  of,  657 
Spino-umbilical  line,  395 
Spinous  processes,  fracture  of, 

657 


698 


INDEX 


Spiral  fractures,  566 
Splay-foot,  630 
Spleen,  440 
capsule  of,  442 

dislocation  of,  441 

enlarged,  441,  442 

extirpation  of,  443 

injuries  to,  442 

relations  of,  440 

rupture  of,  442 

Sprains      (see      the      various 

joints) 

Squamous  suture,  17 
Status  lymphaticus,  234 
Stenson's  duct,  138 
Sterno-clavicular  joint,  246 

disease  of,  247 

dislocations  of.  248 

movements  of,  247 

Sterno-ensiform  line,  394 

point,  229,  349,  394 

Sterno-manubrial  joint,  213 
Sterno-mastoid  muscle,  174,  178 
Sterno  -  xiphoid     point,     229, 

394 
Sternum,  214 

caries  of,  215 

dislocation  of,  214 

fracture  of,  214 

— -  gummatous  periostitis  of, 

holes  in,  215 

trephining,  215 

Stomach,  399 

—  air  in,  402 

cancer  of,  235,  407 

— —  contractions  of,  401 
dilatation  of,  400,  402 

fistulas  of,  403 

foreign  bodies  in,  404 

functional     divisions    of, 

400 

lymphatics  of,  404 

•  operations  on,  404,  407 

ptosis  of,  400 

relations  of.  399 

shape  of,  401 

ulcers  of,  403 

wounds  of,  403 

Stone  (see  Calculus) 
Stovaine,    injection    of,     into 

subarachnoid  space,  663 
Strabismus,  58,  60 
Strangulated  bowel,  412 
hernia,  427 

testicle,  503 

Stricture    of    urethra,     spas- 
modic, 497,  521 
Stylo-maxillary  ligament,  180 


Subacromial  bursa,  264 
Subarachnoid  space,  38,  661 

injection  of  stovaine 

into,  663 
Subastragaloid     amputations, 

641 
dislocations  of  foot,  624 

joints,  627 

Subclavian  artery,  176 

—  vein,  177,  184,  204 
Subclavius  muscle,  241 
Subcoracoid      dislocation     of 

humerus,  266,  269 
Subcutaneous    tissue   of    eye- 
lids, 81 

of  scalp,  1 

Subdurai  space,  37,  661 
Subglenoid  dislocation  of  hu- 
merus, 266.  269 
Sublingual  bursa,  153 

gland,  152 

Submandibular  duct,  151 

-  glands,  152,  206 
Subperitoneal   connective   tis- 
sue, 357 

Subpyloric  lymphatics,  404 
Subscapular  glands,  223 
Subscapularis  muscle,  240 
Subserous  tissue  of  pelvis,  474 
Subspinous  dislocation  of  hu- 
merus, 266,  269 

Superficial  cervical  glands,  206 
nerve,  177 

epigastric  vein,  350 

sensibility,  nerves  of.  338, 

345 

Superior  frontal   convolution, 
47 

erluteal  artery,  530 

longitudinal  sinus,  36 

maxilla,  139 

(see  also  Maxilla) 

— -  mesenteric  artery,  350 

plexus,  459 

temporal  convolution,  46 

— -  thyroid  artery,  175,  199 

vena  cava,  230 

Supernumerary    auricles,    87, 

211 

—  mammae,  223 

in   femoral  triangle, 

535 

—  nipples,  223,  535 
Supination,  304 
Suppuration  (see  Abscess) 
Supraclavicular  nerves,  177 
Supracondyloid    process,    279, 

289 
Supracubital  gland,  288 


INDEX 


699 


Suprahyoid  lymphatic  glands, 

206 

Supraorbital  foramen,  125 
Suprapancreatic     lymphatics, 

404 

Suprapubic  lithotomy,  482 
Suprarenal  artery,  350 

bodies,  454 

internal  secretion  of, 

454 

tumours,  454 

Suprascapular  artery,  177,  252 

—  notch,  252 

Suspensory    ligament   of    eye- 
ball, 58,  75 

of  lens,  74 

of  pelvic  viscera.  472 

Sustentaculum  tali,  607 

fracture  of,  634 

Sutural  bones,  21 
Sutures  of  skull,  17,  19,  29 
closure  of,  24 

separation  of,  29 

Sycosis  of  eyelids,  82 
Sylvius,  fissure  of,  45 
Symblepharon,  83 
Syme's  amputation,  637 
Sympathetic      cord,      cervical 

part  of,  injury  to,  205 
ophthalmia,  74 

pains,    146,    344,    361,    459, 

469,  547,  601,  619 
;  Symphysis  pubis,  468 
Synechije,  68 
Synostosis  of  skull,  24 
Synovial  cavities  of  foot,  637 
—  of  hand,  332 

membrane  of  knee-joint, 

580 
sacs,  of  hand,  323 

sheaths  of  ankle,  613 

of  hand,  332 

Synovitis  in  hip-joint,  543 

in  knee-joint,  582 

Syphilis,  hereditary,  18 
Syringo-myelocele,  673 

Tabatiere  anatomique.  315 
Tagliacozzi's  operation,  277 
Talipes  calcaneo-valgus,  628 

calcaneo-varus,  628 

calcaneus,  628,  630 

equino-valgus,  628,  630 

equino-varus,  628,  630 

equinus.  628,  630 

mixed  forms  of,  630 

valgus,  629,  630 

—  varus,  628,  630 
Talma-Morrison  operation,  462 
Talus,  dislocation  of,  624 


Talus,  fracture  of,  634 

Tarsal  bones,  633 

fractures  of,  633 

ossification  of,  635 

—  glands,  81 

plate,  80 

Tarsectomy,  630 
Tarso-metatarsal  joints,  640 
Tarsus  (see  Tarsal  bones) 
Teeth,  147 

alveolar  abscess  and,  148 

—  caries  of,  146 

permanent,  147 

— -  temporary,  147 

—  wisdom,  149 

Temporal     convolution,     infe- 
rior, 48 

fascia,  7 

fenestra,  31,  33 

fossa,  abscesses  in,  8 

lobe,  43 

—  region,  7 

trephining  in,  12 

Temporo  -  maxillary    articula- 
tion, 143 

dislocation  at,  144 

—  movements  of,  143 

subluxation  of.  143 

Tendo  Achillis,  599,  608,  615,  616 

calcaneus,  599,  608,  615,  616 

—  oculi,  84 
Tenon,  capsule  of,  57 
Tenotomy    of    biceps    femoris 

tendon,  575 

Tensor  palati,  163,  165 
Testicle,  502 
descent  of,  370.  502 

fibrous  tunic  of,  504 

—  in  femoral  triangle,  535 
— -  inflammation  of.  497 

inversion  of,  503 

—  lymphatics  of,  504 

—  mesentery  of,  503 

—  nerve  supply  of,  504,  522 

—  retained,  502 

— •  strangulated.  503 

—  torsion  of,  503 
Thecal  abscess,  324 
Thenar  eminence,  312 
Thigh,  561 

—  amputation  of,  568 
at  hip-joint.  559 

blood-vessels  of,   534,   562, 

564.  568 

fascia  of,  562 

fracture  of,  565 

shortening    of    limb 

after,  566 

muscles  of,  560,  563,  568 

rupture  of,  564 


700 


INDEX 


Thigh,  nerves  of,  560,  562,  568 
skin  of.  562 

—  surface  anatomy  of,  561 
Third  nerve,  paralysis  of,  62 
Thoracic  duct,  208,  462 
and    cancer    dissem- 

mination,  235 

—  as    a    possible    chan- 

nel    for     tubercu- 
lous infection.  235 

Thoracoplasty,  219 

Thorax,  212 

deformities  of,  213 

paracentesis  of,  217 

viscera  of,  224 

X  -  ray    examination 

of,  232 

walls  of,  212 

• wounds  of,   225 

Throat,  cut,  185 

Thumb,  amputation  of,  334 

• dislocation  of,  332 

Thymus,   195,  234 
Thyro-glossal  duct,  198 
Thyro-hyoid      space,     wounds 

across,  185 
Thyroid  artery,  inferior,   199 

superior,  175,  199 

body,  196 

• accessory   glands   of, 

198 

—  atrophy  of,   199 

—  development   of,   198 
• in  tracheotomy,   194 

-  isthmus  of,  194,  198 
• —        —  lymphatics  of,  199 

cartilage,  188 

• cysts,  congenital,   153 

—  dislocation,  554,  558 
Thyroidea  ima  artery,  199 
Thyrotomy,  192 

Tibia,  596 

and   fibula,   fractures  of, 

602 

—  epiphysis  of,  594 

fractures  of  lower  end  of, 

603 

of  upper  end  of,  591 

ossification  of,  592 

—  rickets  affecting,  604 
Tibial  arteries,  597,  609,  617 

nerve,  572,  609,  610,   645 

Tibialis  anticus  muscle,  596 

tendon,  608,  616 

—  posticus  tendon,  607,  609 
Tibio-flbular  ligaments,  620 
Toe,  great,  dislocation  of,  635 
Tongue,  154 

accessory  glands  of,  158 


Tongue,  blood  supply  of,  155 
— —  cancer  of,   159 

—  epithelium  of,  155 
excision  of,  159 

lymphatic  glands  and  ves- 
sels of.  157,  208 
— -  lymphoid  tissue  in,  157 

—  nerves  of,   155 
Tongue-tie,  154 
Tonsil,  168 

•  blood  supply  of,  171 

hypertrophy  of,  168 

—  causing  deafness,  171 
lingual,  157 

Luschka's,  100 

—  lymphatic  glands  of,   208 

malignant  growths  of,  172 

—  pharyngeal,  100,  167 
Tonsillar  recess,  170 
Torus  palatinus,  162 
Trachea,  186,  228 

foreign  bodies  in,  196,  228 

wounds  of,  186 

Tracheotomy,  192,  193 
Transfusion,  287 
Transpyloric  plane,  394 
Transversalis  fascia,  381 
Transverse  cervical  artery,  177 

colon,  424 

ligament,  612,  620 

—  process  of  atlas,  173 

• of  cervical  vertebrae, 

173 
-•—  — —  of   lumbar  vertebrae, 

652,  657 

Trapezium,  312 
Trapezius,   paralysis  of,   250 
"Tread"  in  talipes,  630 
Trephining,  12 
for  cerebellar  abscess,   14 

for  cerebral  abscess,  12 

tumour,  15 

for  fractured   and    dislo- 

cated spine,  657 

for      meningeal     haemor- 

rhage,  12 

—  in  temporal  region.  12 
Triangular  ligament,   480,   482 
Trigone,  487,  488 
Tripodism,  470 

Trismus.  147 

Tuber  ischii,  465,  524 

Tumour,  blood,  of  scalp,  7 

—  on  pinna.  90 

cerebral,    trephining   for, 

15 

fluid,  of  vertebral  canal, 

673 

mediastinal,  234 


INDEX 


701 


Tumour  of  spinal  cord,  674 
parotid,  138 

phantom,  355 

renal,  453- 

sacro-coccygeal,  470 

scapular,  252 

suprarenal,  454 

—  venous,  of  skull,  10 
Tunica  abdominalis,  351 
albuginea,  504 

—  vaginalis,  371 
Turbinate  body,  112 

—  process,  middle,  111 
Tympanic  membrane,  91 

—  sinus,  95 
Tympanum,  94 
attic  of.  93 

blood  supply  of,  101 

lymphatics  of,  101 

Typhlitis,  418 

Ulna,  dislocation  of,  293 

-  fracture  of,  305 

relations  of,  with  radius, 

303 
Ulnar  artery,  276,  302 

—  collateral    ligament,    291, 

292 

nerve,  276,  289,  337.  341 

—  paralysis  of,  280,  346 
section  of,  345 

vein,  287 

Umbilical  fistula,  355 
hernia,  354 

-  line,  394 
Umbilicus,  348 

—  fibrous  ring  of,  354 

vessels  of,  339 

Umbo,  93 

Upper  limb,  epiphyses  of.  334 
— -  nerve  supply  of,  335, 

340 
Urachus,  354 

patent,  355 

Ureter,  354,  451,  454,  483,  484 

—  distension  of,  456,  489 

double,  451 

exposure  of,  458 

-  kinking  of,  451 

—  relations  of.  454 

—  resection  of,  456 

—  rupture  of,  456 

X-ray  examination  of,  457 

Urethra,  female,  499 
male,  495 

—  and  gonorrhoea,  498 
canal  of,  495,  496 

catheterization      of. 

495 


Urethra,  male,  curve  of,  495 

—  meatus  of,  497 

—  mucous      membrane 

of,      urethroscopic 
examination  of,  498 

—  narrowest    parts    of, 

498 

—  pelvic,  495 

—  perineal,  495 

-  rupture  of,  499 

—  spasmodic     stricture 

of,  497 

—  sphincter  of,  495,  496 

—  membranous,  480,  497 
nerve  supply  of,  520,  521 

penile,  495,  497 

—  prostatic.  496 
Urethral  triangle,  475,  479 
Urethroscopic       examination, 

498 
Urine,     extravasated.     course 

of,  479,  480 

Utero-sacral  ligaments,  474 
Uterus,  508 

—  artery  of,  508 

-  lymphatics  of,  508 

masculinus,  498 

—  neck  of,  508 

—  wounds  of,  509 

Vagina,  507' 

—  attachments  of,  473 

—  wounds  of,  508 
Vaginal  cystocele.  507 

—  enterocele,  507 

process,  369,  371,  374 

—  reotocele,  507 
Valsalva's  method  of  inflating 

middle  ear,  99 
Valves  in  veins  of  neck,  204 
Varicocele,  506 
Varicose  veins,  506,  538,  599 
Vas  aberrans,  279 

deferens,  504,  509 

rupture  of,  504 

Vasa  efferentia.  510 
Vaso-motor    system   of   Tipper 

limb,  disturbances  of,  339 
Vastus  internus  muscle,  561 
Vater,    ampulla   of,    438,    443, 

444 
Veins,  air  in,  204 

—  emissary,  of  skull,  9 
of  Galen,  40 

—  of  neck,  valves  in,  204 

—  (see  also  various  regions) 
Venesection  at  elbow,  287 
Venous  sinuses,  36 

—  tumours  of  skull,  10 


702 


INDEX 


Ventricles,  lateral,  48 
Vertebra  (see  Spine) 

—  prominens,   173 
Vertebrae,  caries  of,  385 
Vertebral  artery,  52,  53 
ligature  of,  204 

— r-  canal,     congenital     mal- 
formations of,  672 
—  fluid  tumour  of,  673 

points     of     exit     of 

nerves  from,  669 

column,  647 

(see  also  Spine) 

Vesico-vaginal  fistula.  508 
Viscera,  abdominal,  386,  432 
pelvic,  fixation  and  move- 
ments of,  473 

—  thoracic,  224 
Visceral  fascia,  473 

spinal  centres,   363 

— —  supports,  395 
Visceroptosis,  393 
Vitello-intestinal  duct,  355,  411 
Vitreous  humour,  78 

—  table,"  25 

Vocal  cords,  189 

Volvulus,  431 

Vomiting,  severe,  in  spinal  in- 
juries. 672 

Vulva,  507 

"  Weaver's  bottom,"  530 
Wharton's  duct,  151 
White  line  of  levator  ani,  472 
Whitlow,  318,  324 
Winged  scapula,  251 
Winslow,  foramen  of,  391 
Wirsung,  duct  of,  443 
Wisdom  teeth,  149 
Wolffian  duct,  509 

—  tubules,  510 
Wolff's  law,  586 
"  Word-seeing  "  centre,  47 
Wormian  bones,  21 
Wrist,  310 


Wrist-joint,  311 

—  amputation  at,  333 
dislocations  at,  332 

— -  epiphyses  about,  334 

—  fractures  about,  329 

—  movements  of,  328 

strength  of,  327 

—  surface  anatomy  of,  310 

synovial  cavities  of,  332 

sacs  and  sheaths  of, 

323 

tendons  about,  321 

Wry-neck,  178 

Xiphisternal  joint,  214 
X-ray    appearance    of    pituit- 
ary fossa,  43 

examination  in  fractures 

about   wrist,   331 
in     spinal     injuries, 

657 

of  appendix,  420 

of  bladder,  484 

—  of  caecum,    417 

_ —  of  dislocated      knee, 

589 

—  of  kidney     and    ure- 

ter, 446 

—  of  movements  of  bis- 

muth -  laden    food. 
422 

—  of  positions  of  abdo- 

minal viscera,  393, 
395 

—  of  tarsal   bones,   634 
of    temporal    region 

of  skull,   31 

. —  of    thoracic    viscera, 

232 

—  of  ureter     for     gall- 

stones, 457 

Zygoma    as    guide    to    struc- 
tures,  16,  43 

fracture  of,  16 


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